Çocuk ve Ergen Psikiyatri Kliniğinde Yatan Hastalarda Kendine Zarar Verme: Klinik Korelasyonlar ve Hematolojik Bulgular

Abstract

Amaç: İntihar girişimi içermeyen kendine zarar verme davranışı (KZVD), çocuk ve ergen psikiyatrisinde yaygın bir sorundur ve sıklıkla uyumsuz bir başa çıkma mekanizması olarak görülmektedir. Psikiyatri yataklı servislerinde sık gözlemlenmesine rağmen, klinik ve biyolojik belirleyicileri, özellikle hematolojik parametrelerle ilişkisi yeterince araştırılmamıştır. Bu çalışma, psikiyatri yatış hastalarında KZVD prevalansını, ilişkili psikiyatrik sosyodemografik faktörleri ve hematolojik parametreleri incelemeyi amaçlamaktadır. Yöntem: Bu çalışmaya, Çocuk ve Ergen Psikiyatrisi Yataklı Servisi’nde yatan 10–18 yaş arası hastalar dahil edilmiştir. Psikiyatrik değerlendirme, Çocuklar İçin Duygudurum Bozuklukları ve Şizofreni Tarama Programı kullanılarak yapılmıştır. Katılımcılar, KZVD öyküsü olanlar ve olmayanlar olarak iki gruba ayrılmıştır. Bulgular: Hastaneye yatırılan ergenlerde en yaygın yöntemi kendini kesme olarak bulunmuştur. Ana motivasyonlar huzursuzluk (%63,9) ve zorluklarla baş etme (%13,9) idi. KZVD grubu, cinsel istismara maruz kalma (p = 0,0001) ve intihar girişimi (p < 0,0001) açısından anlamlı derecede daha yüksek oranlara sahipti. En yaygın psikiyatrik tanı depresif bozukluk idi (p = 0,03) ve KZVD grubundakilerin %70,2’sinin en az bir eş tanısı mevcuttu. Hematolojik analizler, KZVD grubunda ferritin seviyelerinin anlamlı derecede düşük olduğunu gösterdi (p = 0,01), ancak diğer hematolojik parametrelerde fark saptanmadı. Lojistik regresyon analizinde, cinsel istismar öyküsü, intihar girişimi öyküsü ve düşük ferritin düzeyleri KZVD için anlamlı yordayıcılar olarak belirlendi. Tartışma: KZVD, psikiyatri yatış hastalarında yaygın olarak görülmekte olup, cinsel istismara uğrama, intihar girişimi öyküsü ve düşük ferritin düzeyleri ile güçlü ilişkiler göstermektedir. İstismar öyküsü, intihar davranışı ve demir metabolizması bozukluklarının taranması risk değerlendirmesini geliştirebilir. Gelecekteki çalışmalar demir metabolizmasının KZVD üzerindeki olası mekanistik rolünü daha ayrıntılı olarak araştırmalıdır.

Keywords

• İntihara yönelik olmayan kendine zarar verme
• Psikiyatrik komorbiditeler
• Cinsel istismar
• Ferritin düzeyleri

Non-Suicidal Self-Injury in Child and Adolescent Psychiatric Inpatients: Clinical Correlates and Hematological Findings

Abstract

Objective: Non-suicidal self-injury (NSSI) is a prevalent concern in child and adolescent psychiatry, often serving as a maladaptive coping mechanism. Despite its frequent occurrence in psychiatric inpatient settings, limited research has examined its clinical and biological correlates, particularly hematological parameters. This study investigates the prevalence of NSSI, its psychiatric and sociodemographic associations, and hematological parameters in a psychiatric inpatient population. Method: This study included psychiatric inpatients aged 10–18 years. Psychiatric evaluations were conducted using the Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version (K-SADS-PL-DSM-5). Participants were classified into NSSI and non-NSSI groups.. Results: NSSI was observed among hospitalized adolescents, with self-cutting as the most frequent method. The primary motivations were distress (63.9%) and coping with difficulties (13.9%). Adolescents with NSSI had higher rates of sexual abuse exposure (p = 0.0001) and suicide attempts (p < 0.0001). depressive disorder was the most common diagnosis (p = 0.03), with 70.2% of NSSI individuals having at least one comorbid psychiatric disorder. Hematological analyses showed significantly lower ferritin levels in the NSSI group (p = 0.01), while other markers did not differ. Logistic regression identified sexual abuse exposure, suicidal behavior, and low ferritin levels as predictors of NSSI. Discussion: NSSI is highly prevalent among psychiatric inpatients and is strongly associated with sexual abuse history, psychiatric comorbidities, and low ferritin levels. Screening for abuse history, suicidality, and iron metabolism disturbances may enhance risk assessment. Future research should explore the mechanistic role of iron metabolism in NSSI.

Keywords

• Self-Injurious Behavior
• Comorbidity
• Sexual Abuse
• Ferritin

References

1. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th) (Vol.  5). American psychiatric association. https://www. academia.edu/download/38718268/csl6820_21.pdf
2. Asarnow, J. R., Porta, G., Spirito, A., Emslie, G., Clarke, G., Wagner, K. D., ... & Brent, D. A. (2011). Suicide attempts and nonsuicidal self-injury in the treatment of resistant depression in adolescents: findings from the TORDIA study. Journal of the American Academy of Child & Adolescent Psychiatry, 50(8), 772-781.
3. Auerbach, R. P., Kim, J. C., Chango, J. M., Spiro, W. J., Cha, C., Gold, J., ... & Nock, M. K. (2014). Adolescent nonsuicidal self-injury: Examining the role of child abuse, comorbidity, and disinhibition. Psychiatry research, 220(1-2), 579-584.
4. Baiden, P., Stewart, S. L., & Fallon, B. (2017). The role of adverse childhood experiences as determinants of non-suicidal self-injury among children and adolescents referred to community and inpatient mental  health settings. Child abuse & neglect, 69, 163-176.
5. Brown, R. C., & Plener, P. L. (2017). Non-suicidal Self-Injury in Adolescence. Current Psychiatry Reports, 19(3), 1–8. https://doi.org/10.1007/s11920-017-0767-9
6. Chaplo, S. D., Kerig, P. K., Bennett, D. C., & Modrowski, C. A. (2015). The Roles of Emotion Dysregulation and Dissociation in the Association Between Sexual Abuse and Self-Injury Among Juvenile Justice–Involved Youth. Journal of Trauma and Dissociation, 16(3), 272–285. https://doi.org/10.1080/15299732.2015.989647
7. Chesin, M. S., Galfavy, H., Sonmez, C. C., Wong, A., Oquendo, M. A., Mann, J. J., & Stanley, B. (2017). Nonsuicidal Self-Injury Is Predictive of Suicide Attempts Among Individuals with Mood Disorders. Suicide & Life-Threatening Behavior, 47(5), 567–579. https://doi.org/10.1111/sltb.12331
8. Cipriano, A., Cella, S., & Cotrufo, P. (2017). Nonsuicidal Self-injury: A Systematic Review. Frontiers in psychology, 8, 1946. https://doi.org/10.3389/fpsyg.2017.01946

9. Daukantaitė, D., Lundh, L.-G., Wångby-Lundh, M., Claréus, B., Bjärehed, J., Zhou, Y., & Liljedahl, S. I. (2021). What happens to young adults who have engaged in self-injurious behavior as adolescents? A 10-year follow-up. European Child & Adolescent Psychiatry, 30(3), 475–492. https://doi.org/10.1007/s00787-020-01533-4
10. Dougherty, D. M., Mathias, C. W., Marsh-Richard, D. M., Prevette, K. N., Dawes, M. A., Hatzis, E. S., Palmes, G., & Nouvion, S. O. (2009). Impulsivity and clinical symptoms among adolescents with non-suicidal self-injury with or without attempted suicide. Psychiatry research, 169(1), 22–27. https://doi.org/10.1016/j.psychres.2008.06.011
11. Evans, Joanne, H. Platts, and A. Liebenau. “Impulsiveness and deliberate self‐harm: a comparison of ‘first‐ timers’ and’repeaters ‘.” Acta Psychiatrica Scandinavica 93, no. 5 (1996): 378-380.
12. Ford, J. D., Hartman, J. K., Hawke, J., & Chapman, J. F. (2008). Traumatic victimization, posttraumatic stress disorder, suicidal ideation, and substance abuse risk among juvenile justice-involved youth. Journal of Child & Adolescent Trauma, 1, 75-92.
13. Glenn, C. R., & Klonsky, E. D. (2010). A multimethod analysis of impulsivity in nonsuicidal self-injury. Personality Disorders: Theory, Research, and Treatment, 1(1), 67–75. https://doi.org/10.1037/a0017427
14. Gromatsky, M. A., He, S., Perlman, G., Klein, D. N., Kotov, R., & Waszczuk, M. A. (2020). Prospective Prediction of First Onset of Nonsuicidal Self-Injury in Adolescent Girls. Journal of the American Academy of Child and Adolescent Psychiatry, 59(9), 1049–1057. https://doi.org/10.1016/j.jaac.2019.08.006
15. Groschwitz, R. C., Kaess, M., Fischer, G., Ameis, N., Schulze, U. M. E., Brunner, R., Koelch, M., & Plener, P. L. (2015). The association of non-suicidal self-injury and suicidal behavior according to DSM-5 in adolescent psychiatric inpatients. Psychiatry Research, 228(3), 454–461. https://doi.org/10.1016/j.psychres.2015.06.019
16. Herpertz, S. (1995). Self-injurious behaviour Psychopathological and nosological characteristics in subtypes  of self-injurers. Acta Psychiatrica Scandinavica, 91(1), 57–q<68. https://doi.org/10.1111/j.1600-0447.1995.  tb09743.x
17. Huan, C., Chengchao, Z., Yaqi, H., Liudi, Z., Jianling, Z., Yuyan, Y., Yongsheng, J., & Furong, W. (2021). Hippocampal proteomic analysis reveals activation of necroptosis and ferroptosis in a mouse model of chronic unpredictable mild stress-induced depression. Behavioural Brain Research, 407. https://doi.org/10.1016/j.bbr.2021.113261
18. Jacobson, C. M., & Gould, M. (2007). The epidemiology and phenomenology of non-suicidal self-injurious behavior among adolescents: A critical review of the literature. Archives of Suicide Research: Official Journal of the International Academy for Suicide Research, 11(2), 129–147. https://doi.org/10.1080/13811110701247602
19. Kaess, M., Parzer, P., Mattern, M., Plener, P. L., Bifulco, A., Resch, F., & Brunner, R. (2013). Adverse childhood experiences and their impact on frequency, severity, and the individual function of nonsuicidal self-injury in youth. Psychiatry Research, 206(2–3), 265–272. https://doi.org/10.1016/j.psychres.2012.10.012
20. Kaufman, J., Birmaher, B., Axelson, D., Perepletchikova, F., Brent, D., & Ryan, N. (2016). K-Sads-Pl Dsm-5. Pittsburgh: Western Psychiatric Institute and Clinic. https://pediatricbipolar.pitt.edu/sites/default/files/ assets/Clinical%20tools/KSADS/KSADS_DSM_5_SCREEN_Final.pdf
21. Kiekens, G., Claes, L., Hasking, P., Mortier, P., Bootsma, E., Boyes, M., Myin-Germeys, I., Demyttenaere, K., Cuijpers, P., Kessler, R. C., Nock, M. K., & Bruffaerts, R. (2023). A longitudinal investigation of non-suicidal self-injury persistence patterns, risk factors, and clinical outcomes during the college period. Psychological Medicine, 53(13), 6011–6026. https://doi.org/10.1017/S0033291722003178
22. Klonsky, E. D. (2007a). Non-suicidal self-injury: An introduction. Journal of Clinical Psychology, 63(11), 1039–1043. https://doi.org/10.1002/jclp.20411
23. Klonsky, E. D. (2007b). The functions of deliberate self-injury: A review of the evidence. Clinical Psychology  Review, 27(2), 226–239. https://doi.org/10.1016/j.cpr.2006.08.002
24. Klonsky, E. D. (2011). Non-suicidal self-injury in United States adults: Prevalence, sociodemographics,  topography and functions. Psychological Medicine, 41(09), 1981–1986. https://doi.org/10.1017/S0033291710002497
25. Li, J., Wang, L., Wang, Z., Zhao, F., Sun, Y., Lu, Y., & Yang, L. (2024). Association between suicide attempts and anemia in late-life depression inpatients. BMC Geriatrics, 24(1), 43. https://doi.org/10.1186/s12877-023-04649-9
26. Lim, K.-S., Wong, C. H., McIntyre, R. S., Wang, J., Zhang, Z., Tran, B. X., Tan, W., Ho, C. S., & Ho, R. C. (2019). Global Lifetime and 12-Month Prevalence of Suicidal Behavior, Deliberate Self-Harm and Non-Suicidal Self-Injury in Children and Adolescents between 1989 and 2018: A Meta-Analysis. International Journal of Environmental Research and Public Health, 16(22), Article 22. https://doi.org/10.3390/ijerph16224581
27. Liu, R. T., Scopelliti, K. M., Pittman, S. K., & Zamora, A. S. (2018). Childhood maltreatment and non-suicidal self-injury: A systematic review and meta-analysis. The Lancet. Psychiatry, 5(1), 51–64. https://doi.org/10.1016/S2215-0366(17)30469-8
28. Maniglio, R. (2011). The role of child sexual abuse in the etiology of suicide and non-suicidal self-injury. Acta Psychiatrica Scandinavica, 124(1), 30–41. https://doi.org/10.1111/j.1600-0447.2010.01612.x
29. Mars, B., Heron, J., Klonsky, E. D., Moran, P., O’Connor, R. C., Tilling, K., Wilkinson, P., & Gunnell, D. (2019). Predictors of future suicide attempt among adolescents with suicidal thoughts or non-suicidal self-harm: A opulation-based birth cohort study. The Lancet. Psychiatry, 6(4), 327–337. https://doi.org/10.1016/S2215-0366(19)30030-6
30. Muehlenkamp, J. J., & Gutierrez, P. M. (2004). An Investigation of Differences Between Self-Injurious Behavior and Suicide Attempts in a Sample of Adolescents. Suicide and Life-Threatening Behavior, 34(1), 12–23. https://doi.org/10.1521/suli.34.1.12.27769
31. Muehlenkamp, J. J., & Gutierrez, P. M. (2007). Risk for suicide attempts among adolescents who engage in non-suicidal self-injury. Archives of Suicide Research: Official Journal of the International Academy for Suicide Research, 11(1), 69–82. https://doi.org/10.1080/13811110600992902
32. Muehlenkamp, J., & Lau, M. M. (2016). SOARS model: Risk assessment of nonsuicidal self-injury. Contemporary Pediatrics, 33(7), 25–31.
33. Nock, M. K., Joiner, T. E., Gordon, K. H., Lloyd-Richardson, E., & Prinstein, M. J. (2006). Non-suicidal self-injury among adolescents: Diagnostic correlates and relation to suicide attempts. Psychiatry esearch, 144(1), 65–72. https://doi.org/10.1016/j.psychres.2006.05.010
34. Nock, M. K. (2009). Why Do People Hurt Themselves? Current Directions in Psychological Science. https://journals.sagepub.com/doi/abs/10.1111/j.1467-8721.2009.01613.x
35. Nolen-Hoeksema, S., & Girgus, J. S. (1994). The emergence of gender differences in depression during adolescence. Psychological Bulletin, 115(3), 424–443. https://doi.org/10.1037/0033-2909.115.3.424
36. Perry, C. J., Fowler, J. C., Bailey, A., Clemence, A. J., Plakun, E. M., Zheutlin, B., & Speanburg, S. 2009). Improvement and Recovery From Suicidal and Self-Destructive Phenomena in Treatment-Refractory Disorders. Journal of Nervous & Mental Disease, 197(1), 28–34. https://doi.org/10.1097/MD.0b013e3181927598
37. Rojas-Velasquez, D. A., Pluhar, E. I., Burns, P. A., & Burton, E. T. (2021). Nonsuicidal Self-Injury Among African American and Hispanic Adolescents and Young Adults: A Systematic Review. Prevention Science: The Official Journal of the Society for Prevention Research, 22(3), 367–377. https://doi.org/10.1007/s11121-020-01147-x
38. Taliaferro, L. A., Almeida, J., Aguinaldo, L. D., & McManama O’Brien, K. H. (2019). Function and progression of non-suicidal self-injury and relationship with suicide attempts: A qualitative investigation with an dolescent clinical sample. Clinical Child Psychology and Psychiatry, 24(4), 821–830. https://doi.org/10.1177/1359104519862340
39. Taylor, P. J., Jomar, K., Dhingra, K., Forrester, R., Shahmalak, U., & Dickson, J. M. (2018). A meta-analysis of the prevalence of different functions of non-suicidal self-injury. Journal of Affective Disorders, 227, 759–769. https://doi.org/10.1016/j.jad.2017.11.073
40. Unal, F., Oktem, F., Cetin Cuhadaroglu, F., Cengel Kultur, S. E., Akdemir, D., Foto Ozdemir, D., Cak, H. T., Unal, D., Tiras, K., Aslan, C., Kalayci, B. M., Sultan Dogan, B., Kutuk, F., Yanar, E., Karaokur, R., Karabucak, B., Karakok, B., Karaer, Y., & Artik, A. (2019). Reliability and Validity of the Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version, DSM-5 November 2016-Turkish Adaptation (K-SADS-PL-DSM-5-T). Turkish Journal of Psychiatry, 30(1). https://doi.org/10.5080/u23408
41. Wilkinson, P., & Goodyer, I. (2011). Non-suicidal self-injury. European Child & Adolescent Psychiatry, 20(2), 103–108. https://doi.org/10.1007/s00787-010-0156-y
42. Wilkinson, P., Kelvin, R., Roberts, C., Dubicka, B., & Goodyer, I. (2011). Clinical and psychosocial predictors of suicide attempts and nonsuicidal self-injury in the Adolescent Depression Antidepressants and Psychotherapy Trial (ADAPT). American Journal of Psychiatry, 168(5), 495–501. https://doi.org/10.1176/appi.ajp.2010.10050718
43. Yue, W., Yan, L., Zhonghao, W., Zhi, C., Heming, Y., Yong, H., Yu, T., Tianlan, L., Mengge, B., Xiangyu, C., Ke, C., & Peng, X. (2021). Ferritin disorder in the plasma and hippocampus associated with major depressive disorder. Biochemical and Biophysical Research Communications, 553. https://doi.org/10.1016/j.bbrc.2021.03.059
44. Zheng, Q., Liu, J., Ji, Y., Zhang, Y., Chen, X., & Liu, B. (2022). Elevated levels of monocyte-lymphocyte ratio and platelet-lymphocyte ratio in adolescents with non-suicidal self-injury. BMC Psychiatry, 22(1), 618. https://doi.org/10.1186/s12888-022-04260-z