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Adolescence is a critical period for early identification and intervention of borderline personality disorder (BPD). Risk-taking and self-harm behaviors (RSB) have been identified as promising early markers of BPD and correlates of depression in school-based samples. The present study aimed, first, to examine the association between RSB and BPD in a clinical sample of adolescents and, second, to examine whether RSB are also linked to depression. N = 405 participants (82.7% female) were recruited from an outpatient clinic for adolescents with RSB. RSB assessed included truancy, excessive media use, alcohol, tobacco, and illicit drug use, sexual risk-taking, and self-harm behavior. Regression analyses and generalized linear models were performed to examine the associations between individual RSB or patterns of RSB (identified using latent class analysis, LCA) and a diagnosis and severity of BPD or depression. All RSB (except excessive media use) were positively associated with BPD diagnosis and severity. In contrast, only non-suicidal self-injury (NSSI) and suicide attempts were positively associated with depression diagnosis and severity, while illicit drug use was negatively associated with depression severity. The LCA yielded two classes differing in the occurrence of RSB. The high RSB class was more likely to have a BPD diagnosis and greater BPD severity than the low RSB class. Classes did not differ regarding depression diagnosis or severity. As NSSI and suicide attempts were associated with both BPD and depression, the presence of additional RSB, besides self-harm behavior, may represent a specific risk marker for BPD in adolescents.

Background Bullying victimization affects one in ten schoolchildren in Europe and has far-reaching negative consequences for mental health and school achievement. Although school-based bullying prevention programs seem overall capable of reducing the frequency of bullying, the continuous development, improvement, and rigorous evaluation of bullying prevention programs with enhanced feasibility and efficacy is critical. Consequently, we developed the program Bullying&You , which applies a blended-intervention approach to school-based bullying prevention based on latest empirical knowledge regarding effective program components and program-related facilitators. We aim to test its efficacy within a cluster randomized trial (CRT). Methods Bullying&You will be implemented and evaluated in 40 schools (estimated total  n  = 8500 pupils) in Germany. The effectiveness of the program will be investigated in a CRT comparing 20 schools in the intervention group (IG; starting immediately with the program) with 20 schools in the waiting control group (CG; starting with a 1-year delay). The target group of the program are pupils in grades 3–9, as well as the whole school staff. All pupils will be asked to complete questionnaires concerning their bullying experiences (as victims, perpetrators, and bystanders) and mental health at baseline (T0) and two annual follow-ups (T1 and T2). The main endpoint of the trial is the reduction of bullying (prevalence of victims and perpetrators of direct, indirect, and cyberbullying) at 1-year follow-up (T1) in the IG compared to the CG. Secondary endpoints are psychopathology and self-harm behaviour. In addition, further research questions include (a) which specific components of the program prove to be most effective and (b) whether there are certain characteristics that predict program success at the individual level. Discussion School-based bullying prevention programs still lack rigorous evidence for their efficacy. In addition, dissemination of bullying prevention programs has previously been hampered by the high need of resources required from schools for their implementation. The program’s blended-intervention approach allows for a time-efficient and flexible implementation, while the continuous monitoring of the progress ensures program fidelity and strengthens adherence. If proven effective, Bullying&You has the potential to contribute to filling the gap in systematic dissemination of bullying prevention among youth. Trial registration German Clinical Trials Register DRKS00028183. Registered on 02 March 2022.

Background Bullying, problematic internet gaming, and problematic social media use are concerning phenomena, especially among youth. However, studies including all three of them are scarce. Therefore, this study investigated the associations between bullying victimization and the two internet-related outcomes. Furthermore, differences between problematic internet gaming and problematic social media use regarding the individual and moderating effects of gender, age, educational background and mental health problems were examined. Methods Adolescents ( N  = 6,735; 48.85% females) answered a school-based survey on bullying, problematic internet gaming, problematic social media use and mental health problems. The age ranged from grade 5 with M  = 10.77 years ( SD  = 0.68) to grade 9 with M  = 14.75 years ( SD  = 0.87) and overall M  = 12.73 years ( SD  = 1.60). A-level school students represented higher educational background (39.52%) while B-level school students represented lower educational background (60.48%). Multilevel modelling was used to examine the associations of bullying victimization with problematic internet gaming and problematic social media use as well as the influences of gender, school grade as a correlate of age, school type and mental health problems. Results Victims of bullying showed higher odds for problematic internet gaming and problematic social media use. Overall, boys showed higher levels of problematic internet gaming, whereas girls showed higher levels of problematic social media use. Younger adolescents reported higher odds for problematic internet gaming, while no age effect was found for problematic social media use. Students with lower educational background and those with more mental health problems reported more problematic social media use than problematic internet gaming. Mental health problems moderated the association of bullying victimization with problematic internet gaming and problematic social media use, with stronger relations for students with less mental health problems. Furthermore, gender was a significant moderator for problematic social media use but not for problematic internet gaming, with a stronger association for boys. Conclusions Bullying victimization is strongly related to different types of problematic internet use. As differences in the impact on problematic internet gaming and problematic social media use can be identified, prevention should also consider gender, age, educational background and mental health problems. Trial registration DRKS00028183.

Internet gaming disorder (IGD) was included in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) as a research diagnosis, but little is known about its pathophysiology. Alterations in frontostriatal circuits appear to play a critical role in the development of addiction. Glutamate is considered an essential excitatory neurotransmitter in addictive disorders. This study’s aim was to investigate striatal glutamate in youth with IGD compared to healthy controls (HC). Using a cross-sectional design, 25 adolescent male subjects fulfilling DSM-5 criteria for IGD and 26 HC, matched in age, education, handedness and smoking, were included in the analysis. A structural MPRAGE T1 sequence followed by a single-voxel magnetic resonance spectroscopy MEGA-PRESS sequence (TR = 1500 ms, TE = 68 ms, 208 averages) with a voxel size of 20 mm 3 were recorded on 3 T Siemens Magnetom Prisma scanner. The voxel was placed in the left striatum. Group comparison of the relative glutamate and glutamine (Glx) was calculated using regression analysis. IGD subjects met an average of 6.5 of 9 DSM-5 IGD criteria and reported an average of 29 h of weekly gaming. Regression analysis showed a significant group effect for Glx, with higher Glx levels in IGD as compared to HC (coef. = .086, t (50) = 2.17, p  = .035). Our study is the first to show higher levels of Glx in the striatum in youth with IGD. The elevation of Glx in the striatum may indicate hyperactivation of the reward system in IGD. Thus, results confirm that neurochemical alterations can be identified in early stages of behavioral addictions.

Beyond psychosis prediction, clinical high-risk (CHR-P) symptoms show clinical relevance by their association with functional impairments and psychopathology, including personality pathology. Impaired personality functioning is prioritized in recent dimensional personality disorder models (DSM-5, ICD-11), yet underexplored in CHR-P, as are associations with cognitive biases, which early studies indicate as possibly linking CHR-P-symptoms and personality pathology. A community sample (  444, 17-60 years, 61.8% female) was assessed via clinical telephone interview and online questionnaires. Using zero-inflated Poisson models, we explored associations of personality functioning, cognitive biases, current psychopathology, and psychosocial functioning with likelihood and severity of overall CHR-P, as well as perceptive (per-) and non-perceptive (nonper-)CHR-P-symptoms distinctly. Higher nonper-CHR-P-symptom likelihood was associated with more impaired personality functioning and psychosocial functioning, while more severe cognitive biases were associated with higher CHR-P- and per-CHR-P-symptom likelihood, alongside higher CHR-P- and nonper-CHR-P-symptom severity. Further, more axis-I diagnoses were linked to higher CHR-P-, per-CHR-P-, and nonper-CHR-P-symptom likelihood, and younger age to higher CHR-P- and per-CHR-P-symptom severity, with CHR-P-symptom severity appearing higher in females. In an exploratory analysis, personality functioning elements identity and self-direction, and cognitive biases dichotomous thinking, emotional reasoning, and catastrophizing, respectively, showed multifaceted associations with nonper-CHR-P-symptom likelihood and overall CHR-P-symptom expression. Our study supports the association of CHR-P-symptoms with multiple mental health factors. Findings suggest intricate associations between personality functioning impairments and cognitive biases with CHR-P-symptom expression in non-help-seeking populations, possibly contributing to different per-CHR-P- and nonper-CHR-P-symptom expression patterns. Therefore, they should be targeted in future longitudinal studies, aiming at better understanding CHR-P-manifestations to inform preventive intervention.

Clinical guidelines for adults with borderline personality disorder (BPD) recommend outpatient psychotherapy as first-line treatment. Little is known whether this recommendation is also applicable to adolescents. The current study examined the relationship between treatment setting and the outcome of early intervention for adolescents with BPD pathology. One-hundred and seventy-eight adolescents from a specialized outpatient clinic were assessed at baseline, and at 1- and 2-year follow-up. Sixty-three participants who received inpatient treatment during the first year were assigned to the “combined inpatient/outpatient group”, 115 participants to the “outpatient only group”. Generalized linear and mixed models with inverted probability weights to adjust for baseline differences were applied to examine the impact of group on clinical changes over time. Both groups demonstrated a significant decrease in BPD features, depressive symptoms, psychopathological distress, non-suicidal self-injury (NSSI), suicidal thoughts, suicide attempts, and overall illness severity, and a significant increase in quality of life and psychosocial functioning from baseline to follow-up 2. The decrease in NSSI and overall illness severity, and the increase in psychosocial functioning from baseline to follow-up 1 were greater in the outpatient only group, with comparable improvements between groups from follow-up 1 to follow-up 2. Both outpatient treatment and combined outpatient/inpatient treatment resulted in clinical improvements over time, with some indication for faster changes in the outpatient only setting. The findings provide preliminary evidence that the recommendation of outpatient psychotherapy as the first-line treatment for BPD also holds true for adolescents.

Purpose Research to date suggests that physical activity is associated with improved sleep, but studies have predominantly relied on self-report measures and have not accounted for school day/free day variability. To address these gaps in the literature, the aim of the present study was to (a) quantify physical activity in adolescents using long-term daily actigraphy measurement and (b) to examine the association between actigraphically assessed steps and sleep behavior in a sample of healthy adolescents. To be able to capture intra- and inter-individual differences in the daily physical activity of adolescents, we examined within as well as between subjects effects and its association with sleep. Methods Fifty adolescents between 10 and 14 years of age were included in the present study. In total 5989 days of actigraphy measurement (average of 119 ± 40 days per participant; range = 39–195 days) were analyzed. We use multilevel modeling to disentangle the within and between subject effects of physical activity on sleep. In this way, we examine within an individual, the association between steps during the day and subsequent sleep on a day-to-day basis. On the other hand, our between subjects’ analysis allows us to ascertain whether individuals with more overall physical activity have better sleep. Results Within a subject more steps on school and free days were associated with later bed times on school and free days as well as later rise times on school days only. On the other hand, comparing between subjects’ effects, more steps were associated with lower sleep efficiency on free and school days. No other significant associations were found for the other sleep variables. Conclusion Our results obtained through objective and long-term measurement of both sleep and number of steps suggest weak or non-significant associations between these measures for most sleep variables. We emphasize the importance of the methodology and the separation of within subject from between subject features when examining the relationship between physical activity and sleep.

Background The long-standing view that auditory verbal hallucinations (AVH) or hearing voices is a sign of schizophrenia has been challenged by research demonstrating that they lie on a continuum ranging from normal to pathological experience related to distress and need for care. Hearing voices is more prevalent in adolescence than in later life, and hearing voices during adolescence indicates a risk for severe psychopathology, functional impairments, and suicide later in life. While there is increasing evidence for the efficacy of cognitive behavioral therapy for voices (CBTv) in adults with schizophrenia, research on psychological treatments for youth with distressing voices has been scarce. The aim of the current study is to examine the efficacy of CBTv, delivered using smartphone-based Ecological Momentary Assessment Intervention (EMI) in a transdiagnostic sample of youth. Methods This is a superiority randomized controlled trial comparing 8 weeks of CBTv-based EMI in addition to treatment as usual (TAU) versus TAU only. TAU covers both no treatment and any form of psychiatric/psychological treatment. In the EMI condition, participants will be prompted twice a day to complete an EMA survey, and receive one intervention proposal per assessment. One-hundred fifty-four youth aged 14–25 years with distressing voices will be recruited from psychiatric clinics, local private practices, internet forums, and advertisements in print and social media. Before and after the intervention phase, participants will undergo a 9-day EMA. Single-blinded assessments will be conducted at baseline (T0) and at 3-month (T1) and 6-month (T2) follow-up. The primary outcome is the distress dimension of the Auditory Hallucinations subscale of the Psychotic Symptom Rating Scales at T1. Secondary outcomes include perceived hostile intention, power, and dominance of voices, passive, aggressive, and assertive relating to voices, and negative core beliefs about the self. Discussion Adolescence provides a crucial window of opportunity for early intervention for hearing voices. However, youth are notoriously reluctant help-seekers. This study offers a low-intensity psychological intervention for youth with distressing voices beyond diagnostic boundaries that, using a mobile technology approach, may match the treatment preferences of the generation of “digital natives.” Trial registration German Clinical Trials Register DRKS00026243. Registered on 2 September 2021

Background Despite the introduction of dimensional conceptualisations of personality functioning in the latest classification systems, such as Criterion A of the Alternative Model of Personality Disorders in the DSM-5 , heterogeneous clinical presentation of personality pathology remains a challenge. Relatedly, the latent structure of personality pathology as assessed by the Semi-Structured Interview for Personality Functioning DSM-5 (STiP-5.1) has not yet been comprehensively examined in adolescents. Therefore, this study aimed to examine the latent structure of the STiP-5.1, and, based on those findings, to describe any unique clinical profiles that might emerge. Methods The final sample comprised 502 participants aged 11–18 years consecutively recruited from a specialised personality disorder outpatient service, as well as general day clinic and inpatient wards at the University Hospital University Hospital of Child and Adolescent Psychiatry and Psychotherapy, University Hospital Bern, Switzerland. Participants were assessed using the STiP-5.1, as well as a battery of other psychological measures by clinical psychologists or trained doctoral students. Variations of Factor Analysis, Latent Class Analysis and Factor Mixture Models (FMM) were applied to the STiP-5.1 to determine the most appropriate structure. Results The best fitting model was an FMM comprising four-classes and two factors (corresponding to self- and interpersonal-functioning). The classes differed in both overall severity of personality functioning impairment, and in their scores and clinical relevance on each element of the STiP-5.1. When compared to the overall sample, classes differed in their unique clinical presentation: class 1 had low impairment, class 2 had impairments primarily in self-functioning with high depressivity, class 3 had mixed levels of impairment with emerging problems in identity and empathy, and class 4 had severe overall personality functioning impairment. Conclusions A complex model incorporating both dimensional and categorical components most adequately describes the latent structure of the STiP-5.1 in our adolescent sample. We conclude that Criterion A provides clinically useful information beyond severity (as a dimensional continuum) alone, and that the hybrid model found for personality functioning in our sample warrants further attention. Findings can help to parse out clinical heterogeneity in personality pathology in adolescents, and help to inform early identification and intervention efforts.

Background The current study evaluated the stepped care approach applied in AtR!Sk; a specialized outpatient clinic for adolescents with BPD features that offers a brief psychotherapeutic intervention (Cutting Down Program; CDP) to all patients, followed by a more intensive Dialectical Behavioral Therapy for Adolescents (DBT-A) for those whose symptoms persist. Methods The sample consisted of 127 patients recruited from two AtR!Sk clinics. The number of BPD criteria, psychosocial functioning, severity of overall psychopathology, number of days with non-suicidal self-injury (NSSI; past month), and the number of suicide attempts (last 3 months) were assessed at clinic entry (T0), after CDP (T1), and at 1- and 2-year follow-up (T2, T3). Based on the T1 assessment (decision criteria for DBT-A: ≥ 3 BPD criteria & ZAN-BPD ≥ 6), participants were allocated into three groups; CDP only ( n  = 74), CDP + DBT-A (eligible and accepted; n  = 36), CDP no DBT-A (eligible, but declined; n  = 17). Results CDP only showed significantly fewer BPD criteria (T2: β = 3.42, p  < 0.001; T3: β = 1.97, p  = 0.008), higher levels of psychosocial functioning (T2: β = -1.23, p  < 0.001; T3: β = -1.66, p  < 0.001), and lower severity of overall psychopathology (T2: β = 1.47, p  < 0.001; T3: β = 1.43, p  = 0.002) over two years compared with CDP no DBT-A, while no group differences were found with regard to NSSI and suicide attempts. There were no group differences between CDP + DBT-A and CDP no DBT-A, neither at T2 nor at T3. Discussion The findings support the decision criterion for the offer of a more intense therapy after CDP. However, there was no evidence for the efficacy of additional DBT-A, which might be explained by insufficient statistical power in the current analysis.