teens with depression and suicide

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©2014, ALL RIGHTS RESERVED ISSN: 1555–7855

INTERNATIONAL JOURNAL OF BEHAVIORAL CONSULTATION AND THERAPY 2014, VOL. 9, NO. 3

Adolescent suicide and self-injury: Deepening the understanding of the biosocial theory and applying dialectical behavior therapy Elizabeth A. Courtney-Seidler, Karen Burns, irene Zilber, and Alec L. Miller Cognitive & Behavioral Consultants, LLP – White Plains, NY

Abstract The promise of Dialectical Behavior Therapy (DBT) has been substantiated by a growing body of work demonstrating its efficacy for addressing suicidal and non-suicidal self-injury as well as pervasive emotional and behavioral dysreg- ulation, among adolescents. Research elucidating the neurobiological correlates and biosocial factors contributing to the development of emotion dysregulation and self-harm is presented. A recent milestone is the completion of the first randomized controlled trial of DBT with self-harming adolescents. The results of this five-year study are presented along with an overview of the treatment as adapted for this population.

Keywords Dialectical Behavioral Therapy (DBT), suicidal and non-suicidal self-injury, emotional and behavioral dysregulation, adolescents, self-harm, neurobiological correlates, biosocial factors, randomized controlled trial.

Dialectical Behavior Therapy (DBT) was first adapted for use with multi-problem suicidal adolescents nearly twenty years ago in response to a dearth of empirically supported psychosocial treatments for this population (Miller, Rathus & Linehan, 2007; Miller, Rathus, Linehan, Leigh & Wetzler, 1997). Miller, Rathus and colleagues retained the core principles and strategies of Linehan’s (1993) original DBT treatment manual for suicidal women with Borderline Personality Disorder (BPD), and made modifications based on developmental and contextual considerations for adolescents and their families. Three review articles by Groves, Backer, van den Bosch, & Miller (2012), MacPherson, Cheavens, & Fristad (2013), and Neece, Berk, & Combs-Ronto (2013) all found growing evidence, based on the review of over a dozen quasi-experimental and open-trial pilot studies, to suggest that DBT may be a promising treatment for adolescents with a range of problematic behaviors, including but not limited to suicidal and non-suicidal self-injury. Ritschel, Miller & Taylor (2013) recently proposed DBT as transdiagnostically applicable to adoles- cents who present with more pervasive emotional and behavioral dysregulation often evidenced in mood disorders, substance use disorders, eating disorders, and disruptive behavior disorders, in addition to the more standard applications of DBT to self-harming individuals often diagnosed with BPD. More recently, Mehlum and colleagues (in press) have completed the first randomized con- trolled trial of DBT with self-harming adolescents and found DBT to be a highly effective treatment for this population.

This paper reviews adolescent suicide and self-in- jury and the neurobiological bases for some of these behaviors. Next the paper provides further support for Linehan’s (1993) Biosocial theory of emotion dysregulation, that informs DBT treatment with adolescents. Finally, the paper briefly describes DBT treatment with adolescents along with a brief review of the results of the first adolescent DBT randomized controlled trial (RCT).

Adolescent suicide and self-injury Suicidal behavior is among the leading causes of death among adolescents (Bridge et al., 2006; Spirito & Esposito-Smythers, 2006). The estimated lifetime prevalence for suicidal ideation, planned attempts, and suicide attempts is 12%, 4%, and 4.1% respectively (Nock et al., 2013). Non-suicidal self-injury (NSSI) is often a correlate and precursor to suicidal behaviors among adolescents (Andover et al., 2012; Miller et al., 2007;). The lifetime prevalence of NSSI in adolescent community samples is 15-28% (Claes, Luycks, Bijtte- bier, 2014; Laye-Gindhu & Schonert-Reichl, 2005; Nixon et al., 2008; Whitlock & Knox, 2007) and is found in up to 60% of adolescent clinical samples (Nock & Prinstein, 2004). The typical age of onset for NSSI is between 12-14 years (Nixon, Cloutier, & Aggarwai, 2002; Nock & Prinstein, 2004; Ross & Heath, 2002) and cutting and hitting oneself are the most frequent forms of NSSI (Muehlenkamp & Gutierrez, 2004, 2007; Ross & Heath, 2002). Adoles- cents who engage in NSSI are more likely to attempt suicide (Whitlock & Knox, 2007), with 70% of adolescents who engage in NSSI reporting at least one suicide attempt and 55% reporting multiple suicide attempts (Nock, Joiner, Gordon, Lloyd-Richardson, & Prinstein, 2006; Zlotnick, Donaldson, Spirito, & Pearlstein, 1997).

Although suicidal behavior is mentioned as a symptom of Borderline Personality Disorder (BPD) in the DSM-IV and ICD-10 classification systems, and research has provided ample support for this diagnostic relationship (Nock et al., 2006), suicidal and non-suicidal self-injury in adolescence is also detected in internalizing and externalizing disorders (Nock et al., 2006). There is ample research on the diagnostic correlates of suicide and NSSI in adoles- cents (See Nock et al., 2006 for review). Despite the progress in identifying psychosocial risk factors for adolescent suicidal behaviors, such as psychiatric diagnoses, the neurobiological alterations that contribute to the pathogenesis of suicide are less well understood in adolescents (Currier & Mann, 2008; Mann, 2003).

Neurobiology of suicidal behaviors and non-suicidal self-injury Substantial evidence exists supporting the asso- ciation between deficits in 5-HT functioning and conditions and behaviors characterized by impul- sivity, aggression, and affective instability (Kamali, Oquendo, & Mann, 2002). A relationship between the serotoninergic system and suicidal behaviors is the most consistent finding regarding biological contributions to suicidality (Mann, 2003; Zalsman et al., 2006). Pandey and colleagues’ (1997, 2002, 2004) post-mortem research indicates that adolescent suicide completers have increased serotonin 5-HT2a receptors, protein, and mRNA expression in the prefrontal cortex and hippocampus compared to normal controls. More recent research from Pandey and colleagues (2012), found that proinflammatory cytokines, which play an important role in stress and depression, were elevated in the prefrontal cortex compared to normal controls. Brain-derived neurotrophic factor (BDNF) dysregrulation has also been associated with adolescent suicidality, independent of psychiatric diagnoses (De Leo, 2011; Pandey, 2004). BDNF plays a significant role in the regulation and growth of neuronal development in children and adolescents. Research hypothesizes that the serotonin dysfunctions found in adolescents with suicidal behavior may be related to deficits in BDNF (De Leo, 2011).

A majority of neuroimaging studies of NSSI and suicidal behavior have been with adolescents diag- nosed with BPD. Studies have detected alterations in brain maturation with electroencephalography among adolescent females with BPD symptomatology (Ceballos, Houston, Hesselbrock, & Bauer, 2006; Houston, Ceballos, Hesselbrock, & Bauer, 2005). This research and others thus far indicate neurobiological alterations in the anterior cingulate cortex (Chanen, Jovev, et al., 2008; Chanen, Velakoulis et al., 2008; Goodman et al., 2001; Whittle et al., 2009), pituitary gland (Jovev et al., 2008), and the dorsolateral cortex and the orbitofrontal cortex (Brunner et al., 2010). Goodman and colleagues (2011) found that among female adolescents diagnosed with co-morbid BPD and Major Depressive Disorder (MDD), greater BPD symptom severity and number of suicide attempts, and not depression, was associated with greater ACC abnormalities. Research findings of frontolimbic dysfunction in both male and female adolescents with BPD symptomatology and suicidal behaviors support the specific roles of emotion dysregulation and impulsivity in the development of suicidal behaviors.

There is less research on the neurodevelopmental abnormalities in adolescents with NSSI and suicidal behaviors who do not meet criteria for BPD. One neuroimaging study using a heterogeneous diagnostic sample (e.g., MDD, Dysthymia, PTSD, and BPD) compared 18 adolescent females with and without a history of NSSI on an emotional processing task (Plener et al., 2012). Results indicated that adolescent females with NSSI had increased activity in the amygdala, anterior cingulate cortex (ACC) in the inferior and middle orbitofrontal cortex, and reduced sensitivity in the cuneus and right inferior frontal cortex (Plener et al. 2012). Plener and colleagues (2012) argue that these altered neural patterns provide

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COURTNEY-SEIDLER, BURNS, ZILBER, & MILLER36

evidence for adolescents with NSSI having a reduced ability to interpret social cues and regulate emotions. These findings are consistent with a model proposed by Nock (2010) that proposes that increased negative emotions coupled with social problem solving and communication deficits, leads to increased risk for engaging in maladaptive emotion regulation strategies such as NSSI.

Neuroimaging research has found differential patterns of neural activity during emotional pro- cessing…