Functional Connectivity in Antipsychotic-Treated and Antipsychotic-Naive Patients With First-Episode Psychosis and Low Risk of Self-harm or Aggression: A Secondary Analysis of a Randomized Clinical Trial.

Importance: Altered functional connectivity (FC) is a common finding in resting-state functional magnetic resonance imaging (rs-fMRI) studies of people with psychosis, yet how FC disturbances evolve in the early stages of illness, and how antipsychotic treatment influences these disturbances, remains unknown. Objective: To investigate longitudinal FC changes in antipsychotic-naive and antipsychotic-treated patients with first-episode psychosis (FEP). Design, Setting, and Participants: This secondary analysis of a triple-blind, randomized clinical trial was conducted over a 5-year recruitment period between April 2008 and December 2016 with 59 antipsychotic-naive patients with FEP receiving either a second-generation antipsychotic or a placebo pill over a treatment period of 6 months. Participants were required to have low suicidality and aggression, to have a duration of untreated psychosis of less than 6 months, and to be living in stable accommodations with social support. Both FEP groups received intensive psychosocial therapy. A healthy control group was also recruited. Participants completed rs-fMRI scans at baseline, 3 months, and 12 months. Data were analyzed from May 2019 to August 2020. Interventions: Resting-state functional MRI was used to probe brain FC. Patients received either a second-generation antipsychotic or a matched placebo tablet. Both patient groups received a manualized psychosocial intervention. Main Outcomes and Measures: The primary outcomes of this analysis were to investigate (1) FC differences between patients and controls at baseline; (2) FC changes in medicated and unmedicated patients between baseline and 3 months; and (3) associations between longitudinal FC changes and clinical outcomes. An additional aim was to investigate long-term FC changes at 12 months after baseline. These outcomes were not preregistered. Results: Data were analyzed for 59 patients (antipsychotic medication plus psychosocial treatment: 28 [47.5%]; mean [SD] age, 19.5 [3.0] years; 15 men [53.6%]; placebo plus psychosocial treatment: 31 [52.5%]; mean [SD] age, 18.8 [2.7]; 16 men [51.6%]) and 27 control individuals (mean [SD] age, 21.9 [1.9] years). At baseline, patients showed widespread functional dysconnectivity compared with controls, with reductions predominantly affecting interactions between the default mode network, limbic systems, and the rest of the brain. From baseline to 3 months, patients receiving placebo showed increased FC principally within the same systems; some of these changes correlated with improved clinical outcomes (canonical correlation analysis R = 0.901; familywise error-corrected P = .005). Antipsychotic exposure was associated with increased FC primarily between the thalamus and the rest of the brain. Conclusions and Relevance: In this secondary analysis of a clinical trial, antipsychotic-naive patients with FEP showed widespread functional dysconnectivity at baseline, followed by an early normalization of default mode network and cortical limbic dysfunction in patients receiving placebo and psychosocial intervention. Antipsychotic exposure was associated with FC changes concentrated on thalamocortical networks. Trial Registration: ACTRN12607000608460.

Hypothalamic-pituitary-thyroid axis function in female adolescent nonsuicidal self-injury and its association with comorbid borderline personality disorder and depression.

OBJECTIVES: Behavioral disturbances in adolescence are potentially linked to aberrant functioning of the thyroid gland. Accordingly, alterations of the hypothalamic-pituitary-thyroid (HPT) axis might impact psychopathological development. Yet corresponding research in adolescents with nonsuicidal self-injury (NSSI) and comorbid mental disorders is scarce. METHODS: The present study examined HPT axis functioning in adolescents with NSSI compared to healthy controls (HC) using blood-based assays of thyroid-stimulating hormone (TSH), free triiodothyronine (fT3), free thyroxine (fT4), and the ratio of these hormones (fT3/fT4 ratio). Cortisol was additionally examined to contrast HPT axis functioning with a well-established biomarker of stress responsivity. Moreover, associations between clinical characteristics, HPT axis and HPA axis functioning were investigated. Female adolescents meeting NSSI criteria according to DSM-5 criteria (n = 117) were compared to adolescent HC (n = 41). Standardized serum-based endocrinological assays and interview- and questionnaire-based psychiatric assessments were used. Smoking status was included as covariate for all analyses. RESULTS: NSSI patients displayed altered HPT axis functioning as fT3/fT4 ratio values were blunted in comparison to HC. Negative correlations were further present between fT3, fT3/fT4 ratio and severity of BPD symptoms, depression scores and symptomatic distress. TSH correlated negatively with severity of BPD symptoms and symptomatic distress exclusively. Cortisol values differed neither significantly between experimental groups nor correlated significantly with clinical characteristics. CONCLUSIONS: Longitudinal examinations, assessing links between psychopathology and endocrinological alterations, are warranted to address potential clinical implications of thyroid markers in child and adolescent psychiatry.

Self-Injury Is My Drug: The Functions of Describing Nonsuicidal Self-Injury as an Addiction.

ABSTRACT: Adolescents and emerging adults who engage in nonsuicidal self-injury (NSSI) often participate in online activity regarding their self-injury. Of particular importance are the potential benefits and risks associated with online NSSI activity, including how individuals describe their NSSI experiences. One way that individuals describe these experiences is by discussing NSSI as an addiction. Accordingly, we used thematic analysis to explore why individuals may use addiction references to describe their NSSI experiences. To do this, we examined 71 posts from a popular NSSI social network. Four themes emerged: difficulty inherent in stopping, authentication, warn others, and communicate the plight of the behavior. Findings highlight a number of avenues for research as well as implications for clinicians working with clients who self-injure perceive NSSI as an addiction. Mental health professionals can leverage their understanding of clients' perceptions of NSSI to better serve this population.

Long-term outcomes of pediatric traumatic cataracts and retinal detachments due to self-inflicted injuries.

PURPOSE: To report the characteristics and longitudinal visual outcomes of traumatic cataracts and retinal detachments in children with self-inflicted injury. METHODS: A retrospective case series of pediatric patients at a tertiary care center who sustained ocular trauma due to self-inflicted injury between 2000 and 2014. RESULTS: A total of 11 children, all with an intellectual disability and a mean age of 10 ± 4.8 years (range, 2.8-16.2), were identified with traumatic cataract secondary to ocular self-inflicted injury over the study period. Five eyes had a concurrent unilateral retinal detachment. Over the course of follow-up, one additional eye developed a cataract and five eyes developed a retinal detachment. Patients underwent an average of 2.5 ± 2.3 procedures and 17.1 ± 10.7 eye examinations over 11.7 ± 4.2 years of follow-up; 36% required general anesthesia for examination. Visual acuity was improved or preserved in 77% of the eyes that underwent surgical interventions, but was worse in the remaining cases due to development of traumatic retinal detachment. The use of protective helmets, eye shields, and immobilizing orthoses were essential in management of active self-inflicted injury. CONCLUSION: Traumatic cataracts and retinal detachments due to self-inflicted injury may cause severe visual loss. Visual prognosis although poor in children with severe intellectual disabilities may be optimized with risk awareness for early detection and customized interventions.

Sex Differences in the Longitudinal Course and Outcome of Bipolar Disorder in Youth.

OBJECTIVE: Despite substantial literature on sex differences in adults with bipolar disorder (BD), little is known about this topic in youth; this study examines sex differences in mood symptomatology and psychiatric comorbidity in prospectively followed youth with BD. METHODS: A subsample of the Course and Outcome of Bipolar Youth study (N = 370; female n = 199, male n = 171) enrolled October 2000-July 2006 (age at intake = 7-17.11 years) who met DSM-IV criteria for bipolar I disorder (BD-I; n = 221), bipolar II disorder (BD-II; n = 26), or operationalized BD not otherwise specified (BD-NOS; n = 123) with ≥ 4 years follow-up was included. Analyses examined sex differences at intake and, prospectively, in mood symptomatology and psychiatric comorbidity for a mean ± SD follow-up of 10.5 ± 1.72 years. RESULTS: Females were older than males at intake (mean ± SD age = 13.33 ± 3.32 vs 12.04 ± 3.16 years; P = .0002) and at age at mood onset (9.33 ± 4.22 vs 7.53 ± 3.74 years; P < .0001). After adjustment for confounders, males spent more time with syndromal ADHD (Padjusted = .001) and females spent more time with syndromal anxiety (Padjusted = .02). There were trends toward males spending more time with substance use disorder and females having more non-suicidal self-injurious behavior (Padjusted = .07 and .09, respectively). There were no sex differences on outcome variables, including rate of or time to recovery and recurrence. CONCLUSIONS: Contrasting with adult literature, this study identified minimal sex differences in the course of youth with BD. Longer-term studies are needed to clarify if youth-onset BD remains a "sex neutral" subtype of BD or diverges according to sex in adulthood.

Characterization of Severe and Extreme Behavioral Problems in Patients With Alternating Hemiplegia of Childhood.

BACKGROUND: Alternating hemiplegia of childhood often manifests severe or extreme behavioral problems, the nature of which remains to be fully characterized. METHODS: We analyzed 39 consecutive patients with alternating hemiplegia of childhood for occurrence of behavioral problems and categorized those by severity: mild (not requiring intervention), moderate (requiring intervention but no risk), severe (minor risk to self, others, or both), and extreme (major risk). We then analyzed behavioral manifestations, concurrent morbidity, and medication responses in patients with severe or extreme symptoms. RESULTS: Two patients had mild behavioral problems, five moderate, 10 severe, six extreme, and 16 none. Extreme cases exhibited disruptive behaviors escalating to assaults. Triggers, when present, included peer-provocation, low frustration tolerance, limits set by others, and sleep disruption. Reversible psychotic symptoms occurred in two patients: in one triggered by infection and trihexyphenidyl, and in another triggered by sertraline. Of the 16 patients with severe or extreme symptoms, 13 had concurrent neuropsychiatric diagnoses. Occurrence of severe or extreme symptoms did not correlate with age, puberty, severity of intellectual disability, or mutation status (P > 0.05). A multidisciplinary team including mental health professionals comanaged all patients with severe or extreme symptoms with either behavioral therapy, medications, or both. When considering medications prescribed to more than four patients, medicines that demonstrated efficacy or partial efficacy in more than 50% of patients were alpha-adrenergic agonists and selective-serotonin-reuptake-inhibitors. CONCLUSIONS: Patients with alternating hemiplegia of childhood (41%) often experience severe or extreme behavioral problems and, rarely, medication-triggered psychotic symptoms. These observations are consistent with current understanding of underlying alternating hemiplegia of childhood brain pathophysiology. Increasing awareness of these behavioral problems facilitates alternating hemiplegia of childhood management and anticipatory guidance.

The Feeling of Emptiness: A Review of a Complex Subjective Experience.

A feeling of emptiness is commonly encountered in clinical practice, but it is poorly understood, with incongruent approaches to its definition and possible role in various disorders. This review examines the conceptualization of the feeling of emptiness and its place in psychopathology. We found an imbalance between theoretical approaches to this phenomenon and empirical research, and argue that more studies using adequate assessment tools are needed. Based on our literature review, we propose that a feeling of emptiness is a complex, negative emotional state that is experienced in different ways by different individuals. This feeling includes a physical or bodily component, a component of aloneness or social disconnectedness, and a component of a deep sense of personal unfulfillment or lack of purpose. The feeling of emptiness is related to other emotional states (dysphoria, boredom, loneliness, and numbness) and overlaps to some extent with them. Although the feeling of emptiness is most often considered in the context of borderline personality disorder, it is also encountered in depression, narcissistic personality disorder, and schizophrenia spectrum disorders, with its features potentially varying between different conditions. The feeling of emptiness may lead to nonsuicidal self-injury and may also have an important relationship with suicidality. We conclude by offering suggestions for further research, emphasizing a need to refine the multidimensional conceptualization of the feeling of emptiness and to better understand its manifestations and relationships with other emotions within various forms of psychopathology.

Relationship between Internet addiction, susceptible personality traits, and suicidal and self-harm ideation in Chinese adolescent students.

BACKGROUND AND AIMS: Internet addiction (IA) is common among young students. This study aimed to examine the influence and mechanisms of IA and susceptible personality traits on the impact of suicidal ideation in adolescent students in China. METHODS: This cross-sectional study (09/2012-09/2015) used stratified cluster sampling with "school type" for stratification; 136,266 students from 63 schools completed the questionnaire. Logistic regression analysis was performed to estimate the effect of IA (Young's Internet Addiction Test) and susceptible personality (Barratt impulsiveness scale, Buss & Perry Aggression Questionnaire; and Eysenck Personality Questionnaire-R Short Scale) on suicidal ideation (Scale of Suicidal Ideation). RESULTS: Suicidal ideation was observed in 20,218 (14.77%) of the students, and IA was detected in 28,836 (21.16%) subjects. Compared with those without IA, students with IA had a higher prevalence of suicidal ideation (P < 0.0001). No planning impulsiveness had a predictive effect on suicidal ideation in the impulsive personality trait, while in the aggressive personality trait, hostility and self-aggression had a predictive effect on suicidal ideation (all P < 0.0001). High psychoticism and neuroticism were impact factors for suicidal ideation, but extroversion was a protective factor (all P < 0.0001). DISCUSSION: These results highlight the importance of assessing personality traits and reducing IA as a possible means of lessening suicidal ideation. Susceptible personality (such as high psychoticism, high neuroticism, and low extroversion) play a prominent role in influencing the probability of having suicidal behavior among those recently exposed to IA. CONCLUSIONS: IA and susceptible personality traits were significantly correlated with suicidal and self-harm ideation among adolescent students.

Comparative analysis of self-injurious behaviour topographies in young children with and without developmental delay.

BACKGROUND: The present study presents post hoc analyses of specific topographies of self-injurious behaviour (SIB) exhibited by young children with developmental delay (DD) and children with typical development (TD). We conducted these analyses to better understand similarities and differences between the groups from a developmental perspective. No previous study has compared the prevalence, severity and co-occurrence of specific topographies of SIB in young children. METHOD: The participants were parents of two groups of children one with DD (n = 49, mean age = 37.5 months) and one with TD (n = 49, mean age = 36.6 months). Individual items of the SIB subscale from the Repetitive Behaviour Scale-Revised were used in the analyses. RESULTS: Seven of the eight Repetitive Behaviour Scale-Revised SIB categories were reported for both groups. Children in the DD group were significantly more likely to engage in Hits Self against Surface or Object, Hits Self with Body Part, Inserts Finger or Object, Skin Picking and Bites Self. Parental ratings of severity were also significantly greater for the DD group for these five topographies. The DD group engaged in a significantly greater number of SIB topographies than the children in the TD group. Children in the TD group were more likely to exhibit a single SIB topography while the DD group were more likely to engage in two or more topographies. Topographies involving self-hitting were not only more frequent among the children in the DD group but also more likely to be rated as moderate or severe in nature. CONCLUSIONS: Compared with the TD group, the topographies of SIB exhibited by the DD group were more prevalent, more severe and co-occurred with greater frequency. Inclusion of a group of children with TD provided an important comparative context for the occurrence of SIB in children with DD.

The relationship between self-harm and alexithymia: A systematic review and meta-analysis.

Self-harm, defined for the purpose of this review as any act of self-injury without explicit suicidal intent, is an increasing public health concern, with potential long-term implications for those who engage in it. Previous research has identified a correlational relationship between self-harm and alexithymia, an emotion processing deficit characterized by difficulties identifying and describing feelings, and an externally orientated thinking style. Through a systematic search of the literature, the current review examines the association between alexithymia and self-harm. A meta-analysis based on 23 studies found a significant, positive relationship between self-harm and alexithymia, with a medium effect size (g = 0.57, 95% CI 0.46-0.69). All 23 studies used the Toronto Alexithymia Scale (TAS20) to measure alexithymia. The alexithymia subcomponents difficulty identifying feelings and difficulty describing feelings were significantly associated with self-harm, but there was no significant association between self-harm and externally orientated thinking. The effect size of the relationship was significantly larger in adolescent samples compared with adult samples and in female compared with male samples. The definition of self-harm did not affect the effect size of the relationship between alexithymia and self-harm and the results are consistent with previous meta-analyses focused more narrowly on non-suicidal self-injury and, separately, suicidal behaviors. Heterogeneity between the included studies was high. The results support an affect regulation model of self-harm, in which self-harm is used to regulate an emotional experience that is poorly understood.

Development and initial validation of scales to assess Decisional Balance (NSSI-DB), Processes of Change (NSSI-POC), and Self-Efficacy (NSSI-SE) in a population of young adults engaging in nonsuicidal self-injury.

Tools for assessing an individual's readiness to change nonsuicidal self-injury (NSSI) are limited. The Transtheoretical model of change (TTM) has been useful in predicting behavior change and guiding interventions for a variety of health behaviors including eating disorders, substance use disorders, and exercise. The aim of the current study was to examine the validity of test score interpretations from 3 newly developed measures to assess NSSI behavior change. Following in-depth interviews, modifications to existing TTM scales were made and tested with a set of web-based measures delivered to people who self-injure. This resulted in 11 new scales that reflect 3 domains associated with behavior change: NSSI-Decisional Balance (NSSI-DB), NSSI-Processes of Change (NSSI-POC), and NSSI-Self-Efficacy (NSSI-SE). Overall, results provide support for the reliability of test scores and validity of test scores interpretations. Implications for research, clinical use, and next steps are discussed. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Using an ideal observer analysis to investigate the visual perceptual efficiency of individuals with a history of non-suicidal self-injury when identifying emotional expressions.

Individuals who engage in non-suicidal self-injury (NSSI) often report significant interpersonal difficulties, with studies lending support to the idea of impaired social interactions. Perceptual processing deficits of facial expressions have also been associated with interpersonal difficulties, yet little research has assessed how individuals with a history of NSSI (HNSSI) process facial emotions. This study used an ideal observer analysis to assess emotion processing capabilities of these individuals. A total of 30 HNSSI and 31 controls were presented with static images of various facial expressions (fear, anger, disgust, happiness, sadness, surprise) at three intensity levels (50%, 75% and 100% emotion expressivity). Recognition of emotions were measured by signal-proportion thresholds, efficiency scores, and unbiased hit rate. Error responses were also recorded to investigate errors biases made by each group. No significant differences between HNSSI and controls were found in signal-proportion thresholds or efficiency scores. Decreased accuracy of HNSSI participants for recognizing fearful expressions was observed. An increased likelihood of mistaking angry for happy expressions and a decreased likelihood of mistaking sad for surprised expressions were recorded for the HNSSI group compared to controls. These findings provide support to the literature reporting deficits in accurate emotion identification for those engaged in NSSI behaviours.

Developing an understanding of skin picking in people with Prader-Willi syndrome: A structured literature review and re-analysis of existing data.

A search of the PubMed and Web of Science databases for articles on skin picking in PWS was undertaken identifying case studies; trials of specific treatments; and descriptions of when skin picking occurs, what sites are chosen, and what initiates and sustains this behaviour. Published papers have also considered how skin picking might link to the PWS genotype and whether it is best considered to be part of the repetitive and ritualistic behaviours characteristic of the syndrome. To answer specific questions raised as a result of the review additional analysis was undertaken using data from our earlier population-based study of PWS. We consider this behaviour of skin picking using the framework of the Research Domains Criteria that is cross diagnostic and focuses on the identification of specific neurobiological, psychological and cognitive processes. PWS illustrates the likely interplay between different processes that first initiate and then maintain such behaviour. Treatment development depends on better understanding these mechanisms and their relative contribution to the behaviour.

The moderating role of dissociation in the relation between borderline features and factors of self-injury in adolescents.

BACKGROUND: Self-injurious behaviours (SIB) occur frequently in individuals with borderline personality disorder (BPD). While multiple factors may explain the association between SIB and BPD, studies in adults have pointed to dissociation as factor worth considering. However, this relationship has not been examined in adolescents. AIMS: The current study investigated the role of dissociation as a potential moderator between borderline features and SIB, with the expectation that this association would be stronger in the presence of dissociation. METHODS: One hundred forty-four adolescent inpatients were compared on measures of BPD, non-suicidal self-injury (NSSI) and suicidal behaviour. The relationships between borderline features and self-injury outcomes were evaluated using linear and logistic regression with dissociation as a moderator. RESULTS: Borderline features and dissociation were found to be significantly associated with history of NSSI, history of suicide attempt, suicidal ideation (SI) intensity and SI severity. However, dissociation was a significant moderator only in the relationship between borderline features and SI intensity. CONCLUSION: Higher levels of dissociation were associated with more engagement with suicidal thoughts but did not necessarily contribute to SIB. Further research into differential patterns of association of self-injury in patients with BPD may investigate other models where dissociation may more strongly factor into outcomes. © 2020 John Wiley & Sons, Ltd.

Conceptualizing and managing risk in pediatric OCD: Case examples.

It is not uncommon for patients with obsessive-compulsive disorder (OCD) to present with symptoms that suggest possible risk. This can include apparent risk, which reflects the content of obsessional fears, and genuine risk arising as the unintended consequence of compulsive behaviors. In both situations, risk can cause confusion in relation to diagnosis and treatment. The current article adds to the small existing literature on risk in OCD by presenting case examples illustrating different types of risk in the context of pediatric OCD, along with a discussion of their implications for management. The cases highlight that it is crucial that risk in OCD is considered carefully within the context of the phenomenology of the disorder. Guidance is offered to support clinical decision making and treatment planning.

The Relationship Among Shame, Nonsuicidal Self-Injury, and Suicidal Behaviors in Borderline Personality Disorder.

Shame has been individually linked to nonsuicidal self-injury and suicidal ideation and behavior and is highly prevalent in individuals with borderline personality disorder. The current study investigated the relationship between shame, nonsuicidal self-injury, and suicidal ideation in a sample of women with borderline personality disorder. Participants were 40 women recruited from a Women's Dialectical Behavior Therapy Partial Hospital Program in a psychiatric hospital in New England as part of a larger, six-month treatment development study. Results indicated that shame-proneness predicts nonsuicidal self-injury and suicidal ideation and behavior above and beyond the severity of borderline personality disorder symptoms, suggesting that shame may be an important treatment target for individuals with borderline personality disorder. Clinical implications, limitations, and future directions are discussed.

Exploratory analysis of long-term physical and mental health morbidity and mortality: A comparison of individuals with self-inflicted versus non-self-inflicted burn injuries.

INTRODUCTION: Self-inflicted burn (SIB) injuries are relatively rare, but patients may experience complex biopsychosocial challenges. This study aimed to compare long-term physical and psychological outcomes for individuals with SIB and non-SIB injuries. METHODS: Records of adult SIB (n = 125) and non-SIB (n = 3604) injuries were collected from U.S. burn centers within the Burn Model System between 1993 and 2018. Assessments were administered at discharge, 6 months, 24 months, 5 years, and 10 years. RESULTS: SIB patients were more often younger, unmarried, unemployed, male, struggling with pre-morbid psychiatric issues, and injured by fire/flame (all p < 0.001). SIB injury predicted prolonged mechanical ventilation, hospitalization, and rehabilitation (all p < 0.001). After injury, SIB patients had increased anxiety at 24 months (p = 0.0294), increased suicidal ideation at 5 years (p = 0.004), and clinically worse depression at 10 years (p = 0.0695). SIB patients had increased mortality across 24 months compared to non-SIB patients (OR = 4.706, p = 0.010). CONCLUSION: SIB injuries are associated with worse physical and psychological outcomes compared to non-SIB injuries including complicated hospitalizations and chronic problems with anxiety, depression, suicidality, and mortality, even when controlling for common indicators of severity such as burn size. This underscores the importance of multidisciplinary treatment, including mental healthcare, and long-term follow-up for SIB patients. Identified pre-morbid risk factors indicate the need for targeted injury prevention.

Getting Specific about Emotion and Self-Inflicted Injury: An Examination Across Emotion Processes in Borderline Personality Disorder.

This study aimed to examine which specific emotion processes influence self-inflicted injury: basal respiratory sinus arrhythmia, baseline negative emotional intensity, emotional reactivity, or emotion regulation deficits. Self-injuring individuals with borderline personality disorder (N = 22) reported their lifetime self-injury frequency. Basal respiratory sinus arrhythmia and baseline skin conductance responses measurements were collected. Participants then either reacted as they usually would (i.e., emotional reactivity), or utilized mindfulness- or distraction-based strategies (i.e., emotion regulation), in response to negative images while self-reported negative emotion and skin conductance were monitored. Higher basal respiratory sinus arrhythmia and baseline emotional intensity predicted higher lifetime self-injury frequency. Chronic, resting emotion processes may be more important targets for reducing self-injury compared to labile, acute emotion processes.

Could affect regulation via vagal nerve self- stimulation be a maintaining factor in non-suicidal self-harm?

BACKGROUND: Non-suicidal self-injury (NSSI) is a serious and common phenomenon which has been linked with emotion or affect regulation. The capacity for top-down emotion regulation has also been linked to vagal tone. Vagal tone is known to be low in groups with a propensity to engage in NSSI. HYPOTHESIS: Some forms of NSSI, both direct and indirect, may result in vagal stimulation. The resulting increase in vagal tone may be linked to activation of prefrontal areas and improved top-down emotion regulation. This may be a maintaining factor in NSSI. EVALUATION: Cutting with the sight of blood, the use of ligatures, eating disorders and risky sexual behaviour, behaviours that could be considered direct or indirect forms of NSSI, are all plausible methods of vagal self-stimulation. CONCLUSION: NSSI may increase vagal tone. This may result in improved top down emotion regulation and result in a calmer emotional state. These vagal effects may be important maintaining factors in self-harm. This has important implications for the study and possible management of a common and serious issue.