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Background Nonsuicidal self-injury (NSSI) is common among adolescents and associated with negative outcomes. However, treatments developed specifically for NSSI and the proposed NSSI disorder (NSSID) are scarce, and access to empirically supported treatments for NSSI in many areas is limited. Online treatments carry the potential to increase the availability of evidence-based treatments. Emotion regulation individual therapy for adolescents (ERITA) has shown promise in the treatment of adolescents with NSSID. Method The present study examined the feasibility, acceptability, and utility of an online version of ERITA. Twenty-five adolescents (aged 13–17) with NSSID and their parents were included in an uncontrolled open trial. Self-report and clinician-rated assessments of outcomes such as NSSI, self-destructive behaviors, emotion dysregulation, and global functioning were administered at pre-treatment, post-treatment, 3- and 6- month follow-up. Measures of NSSI, self-destructive behaviors, and emotion dysregulation were also assessed weekly during treatment. Results Ratings of treatment credibility, expectancy, and satisfaction were acceptable, and the therapeutic alliance and treatment completion rate (96%) were high. Adolescent participation in the treatment was associated with a statistically significant increase in past-month NSSI abstinence ( p =  .007), large-sized improvements in past-month NSSI frequency (55% reduction, 95% confidence interval [CI]: 29, 72; Cohen’s d  = 0.88, 95% CI: 0.73, 1.06) and global functioning ( d  = 1.01, 95% CI: 0.77, 1.32), and medium-sized improvements in emotion dysregulation ( d  = 0.75, 95% CI: 0.59, 0.90) and NSSI versatility ( d  = 0.63, 95% CI: 0.54, 0.77) from pre- to post-treatment. These improvements were further strengthened at 3-month follow-up and maintained at 6-month follow-up. The online therapist-guided parent program was associated with small- to large-sized ( ds =  0.47–1.22) improvements in adaptive parent behaviors, and these improvements were maintained or further improved upon at 6-month follow-up. Moreover, in line with the theoretical model underlying ERITA, change in emotion dysregulation mediated changes in both NSSI frequency and self-destructive behaviors over the course of treatment. Conclusions Together, results suggest that online ERITA is an acceptable, feasible, and promising low-intensity treatment for adolescents with NSSID. The results of this open trial must be replicated in controlled studies. Trial registration ClinicalTrials.gov ( NCT02697019 ). Registered 2 March 2016

Several treatment-related challenges exist for gambling disorder, in particular at-scale dissemination in health care settings. This study describes the introduction of a newly developed internet-delivered cognitive behavioral therapy (iCBT) program for gambling disorder (GD), provided with therapist support in routine addiction care, in a nationally recruited sample in Sweden. The study details the introduction of the iCBT program, evaluates its effectiveness and acceptability, and compares registry outcomes among iCBT patients with other patients with GD at the clinic who received face-to-face psychological treatment as usual. The study site was the Stockholm Addiction eClinic, which offers digital interventions for addictive disorders in routine care. The iCBT program was introduced nationally for treatment-seeking patients through the Swedish eHealth platform. After approximately 2 years of routine treatment provision, we conducted a registry study, including ordinary patients in routine digital care (n=218), and a reference sample receiving face-to-face psychological treatment for GD (n=216). A statistically significant reduction in the Gambling Symptom Assessment Scale scores during the treatment was observed (B=-1.33, SE=0.17, P<.001), corresponding to a large within-group Cohen d effect size of d=1.39. The iCBT program was rated high for satisfaction. A registry-based survival analysis, controlling for psychiatric comorbidity, showed that patients receiving iCBT exhibited posttreatment outcomes (re-engagement in outpatient addiction care, receiving new psychiatric prescriptions, enrollment in psychiatric inpatient care, and care events indicative of contact with social services) similar to comparable patients who underwent face-to-face treatment-as-usual. A lack of randomized allocation notwithstanding, the iCBT program for GD evaluated in this study was well-received by patients in routine addiction care, was associated with the expected symptom decrease during treatment, and appears to result in posttreatment registry outcomes similar to face-to-face treatment. Future studies on treatment mechanisms and moderators are warranted. RR2-10.1186/s40814-020-00647-5.

Background The knowledge of how the separate Attention-Deficit/Hyperactivity Disorder (ADHD) subdimensions (impulsivity, hyperactivity, and inattention) are associated with nonsuicidal self-injury (NSSI) and suicidal behavior (SB) is limited. The objective of this study was to investigate the associations of childhood ADHD subdimensions with NSSI and SB in children at risk of neurodevelopmental disorders (NDDs; including ADHD). Methods The sample (N = 391) included twin pairs where at least one twin screened positive for at least one NDD or common comorbidity at age 9 or 12. Data on ADHD subdimensions was collected through a telephone interview with a caregiver/legal guardian at age 9 or 12, and data on NSSI and SB was collected through an in-person clinical assessment at age 15. The associations between the ADHD subdimensions and NSSI or SB were tested in three different models: (1) univariable, (2) together with the other ADHD subdimensions, and (3) in a confounder-adjusted model including other NDD symptoms in addition to ADHD subdimensions, for NSSI and SB separately. Results A total of 32 (8.2%) adolescents reported life-time engagement of NSSI, and 18 (4.6%) SB. Childhood impulsivity was associated with SB and childhood inattention with NSSI, in all models. Hyperactivity was not meaningfully associated with any of the outcomes. Conclusion Impulsivity and inattention, but not hyperactivity, may be of particular importance in understanding SB and NSSI. Brief screening for impulsivity and inattention in childhood could facilitate detection of children vulnerable to NSSI and SB and indicate valuable information for preventive and intervention strategies.

Background Nonsuicidal self-injury is a common health problem in adolescents and associated with future suicidal behavior. Predicting who will benefit from treatment is an urgent and a critical first step towards personalized treatment approaches. Machine-learning algorithms have been proposed as techniques that might outperform clinicians’ judgment. The aim of this study was to explore clinician predictions of which adolescents would abstain from nonsuicidal self-injury after treatment as well as how these predictions match machine-learning algorithm predictions. Methods Data from a recent trial evaluating an internet-delivered emotion regulation therapy for adolescents with nonsuicidal self-injury was used. Clinician predictions of which patients would abstain from nonsuicidal self-injury (measured using the youth version of Deliberate Self-harm Inventory) were compared to a random forest model trained on the same available data from baseline assessments. Results Both clinician (accuracy = 0.63) and model-based (accuracy = 0.67) predictions achieved significantly better accuracy than a model that classified all patients as reaching NSSI remission (accuracy = 0.49 [95% CI 0.41 to 0.58]), however there was no statistically significant difference between them. Adding clinician predictions to the random forest model did not improve accuracy. Emotion dysregulation was identified as the most important predictor of nonsuicidal self-injury absence. Conclusions Preliminary findings indicate comparable prediction accuracy between clinicians and a machine-learning algorithm in the psychological treatment of nonsuicidal self-injury in youth. As both prediction approaches achieved modest accuracy, the current results indicate the need for further research to enhance the predictive power of machine-learning algorithms. Machine learning model indicated that emotion dysregulation may be of importance in treatment planning, information that was not available from clinician predictions. Trial Registration NCT03353961|| https://www.clinicaltrials.gov/ , registered 2017–11-21. Preregistration at Open Science Framework: https://osf.io/vym96/ .

Little is known about sex differences in outcomes of self-harm, and there are inconclusive results concerning the association between sex, self-harm, and suicide attempts. The aim of this study was to explore sex differences in outcomes of self-harm in adolescence. In this cohort study, all individuals (0–17 years) enrolled at the child- and adolescent mental health services (CAMHS) in Stockholm between 2001 and 2015 (N = 110,072) were followed in national registers from their last contact with the CAMHS, until end of 2015. Exposure was self-harm as reason for contact, outcome measures were: alcohol-/substance use disorder, psychiatric hospitalization, non-violent or violent crime, and suicide. Differences in outcomes rates between exposed versus unexposed males, and exposed versus unexposed females, were examined using Cox regressions, expressed as hazard ratios (HR) with 95% confidence intervals (CI). Median follow-up time was 5.8 years (Q1: 2.3 years; Q3: 9.7 years). Self-harm was documented in 2.2% (N = 1241) males and 8.7% (4716) females. Exposed individuals had higher HR for all outcomes as compared with unexposed individuals of their own sex. Exposed females had more pronounced risk for drug use disorder (HR 11.2; 95% CI 9.9–12.7) compared with exposed males (HR 6.5, 95% 5.2–8.0). Both males and females who had engaged in self-harm had elevated risks for future suicide. Adjusting for socio-economic status and age at start of follow-up only marginally affected the associations. Females and males with self-harm had similarly elevated risk for suicide, and self-harm was also an important risk marker for other adverse outcomes within both sexes.

The Difficulties in Emotion Regulation Scale (DERS) is extensively used as a measure of emotion (dys-)regulation ability in both clinical and nonclinical populations. This is the first study to examine the factor structure of both the original 36-item and short 16-item version of the DERS in adults with eating disorders and to test measurement invariance across diagnostic subgroups. The factor structure of the scale was examined using confirmatory factor analysis in a psychiatric sample of adults with eating disorders (N = 857). Four primary factor structures were fitted to the data: (1) a unidimensional model, (2) a six-factor correlated-traits model, (3) a higher-order factor solution, and (4) a bifactor model. Measurement invariance was tested for diagnostic subgroups of anorexia nervosa and bulimia nervosa and associations between factors and eating pathology were examined in each diagnostic group. Results indicated that a modified bifactor solution fitted the data adequately for both the 36-item and 16-item version of the DERS. A general factor explained most of the variance (86%) and reliability was high for the general factor of DERS (total) but lower for the subscales. Measurement invariance of the bifactor model was supported across diagnostic subgroups and test of factor means reveled that bulimia nervosa had a higher factor mean than anorexia nervosa on the general factor. The general factor accounted for a significant proportion of variance in eating pathology. Our results support the use of the total scale of both the 36-item and 16-item version among adults with eating disorders.

Background Eating disorders (ED) are associated with symptoms across body image, disordered eating, and exercise-related domains, and while predominantly affecting females, ED in males is also a significant concern. However, popular self-report methods insufficiently capture male presentations. This study aimed (1) to validate the first Swedish translation of the Eating Pathology Symptoms Inventory (EPSI), which was designed to overcome limitations in previous measures, and (2) compare genders gender-specific manifestations of eating pathology, depression, and anxiety in Swedish high-school students. Methods Participants were 359 high-school students (47% males) aged 17.0 years (range 15–21). Results Confirmatory factor analysis and correlation patterns showed support for the 8-factor structure and convergent validity, but poorer discriminant validity may suggest caution in interpreting single scales as evidence of ED pathology. Gender comparisons were broadly consistent with previous research. Conlusions : The Swedish EPSI may be used to asses ED symptoms, but caution is suggested in interpreting some scales in isolation as indicative of ED pathology. Plan English summary Indivudals with eating disorders (ED) experience symptoms that have to do with body image, disordered eating, and physical exercise. Most who get an ED are female, but males are also affected. However, many symptom questionnaires do not capture how males experience their illness very well. In this study, we wanted to (1) test a Swedish translation of the Eating Pathology Symptoms Inventory (EPSI), which was designed to overcome some limitations in other questionnaires, and (2) compare male and female Swedish high-school students on ED symptoms, depression, and anxiety. Participants were 359 students (47% males) aged ≈ 17 years (range 15–21). Statistical analysis showed that the 8 suggested scales of the EPSI overall function as expected, and that the EPSI seems to measure ED symptoms well, but that it also has some overlap with depressive and anxiety symptoms. Males and females differed from one another in ways that resembled what other researchers have found. We conclude that the Swedish EPSI works well, but that some of the scales might not, on their own, suggest that a person has problems with ED, unless other more ED-specific scales also indicate such symptoms.

Background Nonsuicidal self-injury (NSSI) is a serious health risk behavior that forms the basis of a tentative diagnosis in DSM-5, NSSI Disorder (NSSID). To date, established treatments specific to NSSI or NSSID are scarce. As a first step in evaluating the feasibility, acceptability, and utility of a novel treatment for adolescents with NSSID, we conducted an open trial of emotion regulation individual therapy for adolescents (ERITA): a 12-week, behavioral treatment aimed at directly targeting both NSSI and its proposed underlying mechanism of emotion regulation difficulties. Methods Seventeen girls (aged 13–17; mean = 15.31) with NSSID were enrolled in a study adopting an uncontrolled open trial design with self-report and clinician-rated assessments of NSSI and other self-destructive behaviors, emotion regulation difficulties, borderline personality features, and global functioning administered at pre-treatment, post-treatment, and 6-month follow-up. Measures of NSSI and emotion regulation difficulties were also administered weekly during treatment. Results Ratings of treatment credibility and expectancy and the treatment completion rate (88%) were satisfactory, and both therapeutic alliance and treatment attendance were strong. Intent-to-treat analyses revealed significant improvements associated with large effect sizes in past-month NSSI frequency, emotion regulation difficulties, self-destructive behaviors, and global functioning, as well as a medium effect size in past-month NSSI versatility, from pre- to post-treatment. Further, all of these improvements were either maintained or further improved upon at 6-month follow-up. Finally, change in emotion regulation difficulties mediated improvements in NSSI over the course of treatment. Conclusions Results suggest the acceptability, feasibility, and utility of this treatment for adolescents with NSSID. Trial registration ClinicalTrials.gov (NCT02326012, December 22, 2014, retrospectively registered).

Background From a clinical perspective, knowledge of the psychological processes involved in maintaining gambling disorder has been lacking. This qualitative study formulated hypotheses on how gambling disorder is maintained by identifying clinically relevant behaviors at an individual level, as a means to guide the development of new cognitive behavioral interventions. Methods Six individuals from a treatment study, diagnosed with gambling disorder and with diverse symptom profiles of psychiatric comorbidity, were recruited. Participants were interviewed using an in-depth semi-structured functional interview and completed self-report measures assessing gambling behavior. Results Functional analysis was used as a theoretical framework for a thematic analysis, which yielded the following categories: 1) antecedents that may increase or decrease gambling; 2) experiences accompanying gambling; 3) control strategies; 4) consequences of gambling behavior; and 5) events terminating gambling behavior. Few differences were identified in relation to symptom profiles of psychiatric comorbidity, although some gamblers did not report experiencing abstinence when not being able to gamble. Conclusions Gambling is a secluded activity mainly triggered by access to money. Positive and negative emotions could be both antecedents and functions of gambling behavior. Avoidance-based strategies used to control gambling might result in a failure to learn to control gambling behavior. Anticipation, selective attention, and chasing could be important reinforcers, which should be addressed in new developments in cognitive behavioral treatment for gambling disorder.