Adverse childhood experiences as a risk factor for non-suicidal self-injury and suicide attempts in forensic psychiatric patients.

BACKGROUND: Exposure to adverse childhood experiences (ACE) have been found to have profound negative consequences on an individuals' health. Non-suicidal self-injury (NSSI) is a clinically complex and serious global health issue and is closely related to suicide attempts. Previous research has found associations between ACE and NSSI and suicide attempts in clinical samples. However, this association has to our knowledge not been studied to this extent in a sample of forensic psychiatric patients. The aim of this study was therefore to describe the prevalence of adverse childhood experiences (ACE) and their associations with non-suicidal self-injury (NSSI) and/or suicide attempts in forensic psychiatric patients. METHODS: The current study is a cross-sectional study of a consecutive cohort of 98 forensic psychiatric patients (86.7% male) in Sweden. We invited 184 patients with a predicted stay of > 8 weeks who had been cleared for participation by their treating psychiatrist. Of these, 83 declined and 98 eligible patients provided informed consent. Information on ACE, NSSI, and suicide attempts derived from files, self-reports (Childhood Trauma Questionnaire-Short Form; CTQ-SF), and interviews were compared separately among participants with and without NSSI or suicide attempts using t-tests. The dose-response association between ACE and NSSI/suicide attempts was analysed using binary logistic regression. RESULTS: In file reviews, 57.2% of participants reported physical abuse, 20% sexual abuse, and 43% repeated bullying by peers during childhood. NSSI and suicide attempts were associated significantly with CTQ-SF total scores, with medium effect sizes (d = .60 to .63, p < .01), and strongly with several CTQ-SF subscales. Parental substance abuse was also associated with NSSI (p = .006, OR = 3.23; 95% confidence interval [CI] = 1.36 to 7.66) and suicide attempts (p = .018, OR = 2.75; 95% CI = 1.18 to 6.42). Each additional ACE factor predicted an increased probability of NSSI (p = .016, OR = 1.29; CI = 1.04 to 1.59) but not of suicide attempts. When anxiety and depressive disorders were included in the model, ACE remained a significant predictor of NSSI. CONCLUSIONS: We report extensive ACE, from both files and self-reports. When comparing groups, correlations were found between ACE and NSSI, and ACE and suicide attempts among forensic psychiatric patients. ACE seem to predict NSSI but not suicide attempts in this group, even when controlling for affective and anxiety disorders. Early ACE among forensic psychiatric patients, especially physical and emotional abuse and parental substance abuse, have important impacts on self-harming behaviours that must be acknowledged both by the institutions that meet them as children and in their later assessment and treatment.

Adverse childhood experiences do not moderate the association between aggressive antisocial behavior and general disinhibition in a forensic psychiatric inpatient sample.

Adverse childhood experiences (ACE) and high levels of disinhibition have been associated with a variety of negative outcomes such as aggressive antisocial behavior (AAB). However, forensic psychiatric populations remain an understudied group in this field of research. This study aimed to fill that gap by investigating associations between ACE, AAB, and disinhibition in a forensic psychiatric sample. Furthermore, we aimed to explore such findings by investigating whether ACE might have a moderating effect on the association between disinhibition and AAB. A sample of forensic psychiatric patients (n = 89) was recruited from a high-security forensic psychiatric facility in Sweden. All study variables were moderately to strongly related to each other, although we found no moderating effect of ACE. Post hoc analysis indicated that our ACE items had differential effects on AAB scores, with placement outside the family home, absent parents, and parental drug abuse producing the largest effect on AAB levels. Our findings are in line with previous research demonstrating a significant and robust relationship between ACE, AAB, and disinhibition. Forensic psychiatric populations are exposed to high levels of both self-reported and documented ACE. This calls for trauma-informed care and highlights the importance of considering ACE in risk assessment, preventive work, and policy making.

Clinical Characteristics and Self-Harm in Forensic Psychiatric Patients.

Self-harm, comprising non-suicidal self-injury, and suicide attempts, is a serious and potentially life-threatening behavior that has been associated with poor life quality and an increased risk of suicide. In forensic populations, increased rates of self-harm have been reported, and suicide is one of the leading causes of death. Aside from associations between self-harm and mental disorders, knowledge on self-harm in forensic psychiatric populations is limited. The purpose of this study was to characterize the clinical needs of a cohort of forensic psychiatric patients, including self-harm and possible risk factors thereof. Participants (N = 98) were consecutively recruited from a cohort of forensic psychiatric patients in Sweden from 2016 to 2020. Data were collected through file information, self-reports, and complemented with semi-structured interviews. Results showed that self-harm was common among the participants, more than half (68.4%) of whom had at some point engaged in self-harm. The most common methods of non-suicidal self-injury were banging one's head or fist against a wall or other solid surface and cutting, and the most common method of suicide attempt was hanging. The most prominent functions of non-suicidal self-injury among the participants were intrapersonal functions such as affect regulation, self-punishment, and marking distress. Self-harm in general was associated to neurodevelopmental disorders (p = 0.014, CI = 1.23-8.02, OR = 3.14) and disruptive impulse-control and conduct disorders (p = 0.012, CI = 1.19-74.6, OR = 9.41), with reservation to very wide confidence intervals. Conclusions drawn from this study are that self-harm was highly prevalent in this sample and seems to have similar function in this group of individuals as in other studied clinical and non-clinical groups.

Early onset externalizing behaviors among forensic psychiatric patients: Identification in child and adolescent psychiatric services.

Forensic psychiatric patients constitute a heterogeneous patient group, with common comorbidity within the externalizing spectrum. Increased knowledge on early antecedents in the pathway to severe mental illness and criminality is needed. In this study, we investigated early onset externalizing behaviors in three groups of forensic psychiatric patients 1) patients without contact with child and adolescent psychiatry (CAP), 2) patients with CAP contact, and 3) patients with both CAP contact and institutional placement. Participants (N = 98) were consecutively recruited from a cohort of forensic psychiatric patients in Sweden between 2016 and 2020. Data were collected through file information and semi-structured interviews and analyzed with a Bayesian approach. A history of CAP together with an institutional placement during childhood or adolescence was associated with more externalizing disorders, a higher number of convictions over the lifetime, a lower age at first conviction, and a lower age at first self-reported crime. Our findings provide further insight into the importance of early-onset adverse behaviors in the development of later externalizing behaviors, and may be of particular use for practitioners within social services and CAP services.

Emotion Regulation and Self-Harm Among Forensic Psychiatric Patients.

Emotion regulation has been specifically linked to both non-suicidal self-injury (NSSI) and attempted suicide. It is also known that self-harm is disproportionally higher (30-68.4%) in forensic samples than in the general population, yet knowledge about the association between emotion regulation and self-harm in forensic settings is scarce. The purpose of this study was to describe emotion regulation in a sample of forensic psychiatric patients, to explore dimensions and levels of emotion regulation between forensic psychiatric patients with and without self-harm, and to explore associations between forensic psychiatric patients' self-reported emotion regulation and self-reported functions of NSSI. A cohort of forensic psychiatric inpatients (N=98) was consecutively recruited during 2016-2020 from a high-security forensic psychiatric clinic in Sweden. Data were collected through the self-report measures Difficulties in Emotion Regulation Scale (DERS) and Inventory of Statements About Self-injury (ISAS). In relation to the first aim, median total and subscales scores for DERS were reported. Results showed a statistically significant difference in emotion regulation between participants with and without self-harm (p=0.004), with a medium effect size (Cohen's d=0.65) for the DERS total scale. The DERS subscales returned large differences for Impulse (p=0.001, d=0.86), Goals (p=0.014, d=0.58), and Strategies (p=0.012, d=0.54) between participants with and without self-harm. Finally, DERS scores were correlated with both the interpersonal (rs =0.531, p<0.001, n=43) and intrapersonal factors (rs =0.503, p<0.001, n=43) of NSSI as reported on the ISAS. Participants with self-harm (NSSI and/or suicide attempts) demonstrated significantly more difficulties with emotion regulation than those without self-harm. Emotion dysregulation was associated with both interpersonal and intrapersonal functions of NSSI in the participants. We suggest further studies on forensic psychiatric patients' maladaptive behaviors that focus on substance abuse, self-harm, and aggressive behaviors in relation to the regulation and expression of emotion.

Deliberate self-harm behavior among young violent offenders.

Deliberate self-harm behavior (DSH) can have profound effects on a person's quality of life, and challenges the health care system. Even though DSH has been associated with aggressive interpersonal behaviors, the knowledge on DSH in persons exhibiting such behaviors is scarce. This study aims to (1) specify the prevalence and character of DSH, (2) identify clinical, neurocognitive, psychosocial, and criminological characteristics associated with DSH, and (3) determine predictors of DSH among young violent offenders. Data were collected from a nationally representative cohort of 270 male violent offenders, 18-25 years old, imprisoned in Sweden. Participants were interviewed and investigated neuropsychologically, and their files were reviewed for psychosocial background, criminal history, mental disorders, lifetime aggressive antisocial behaviors, and DSH. A total of 62 offenders (23%) had engaged in DSH at some point during their lifetime, many on repeated occasions, yet without suicidal intent. DSH was significantly associated with attention deficit hyperactivity disorder, mood disorders, anxiety disorders, various substance use disorders, being bullied at school, and repeated exposure to violence at home during childhood. Mood disorders, anxiety disorders, and being bullied at school remained significant predictors of DSH in a total regression model. Violent offenders direct aggressive behaviors not only toward other people, but also toward themselves. Thus, DSH must be assessed and prevented in correctional institutions as early as possible, and more knowledge is needed of the function of DSH among offenders.