Catherine R. Glenn, PhD - US grants

DESCRIPTION (provided by applicant): Non-suicidal self-injury (NSSI) describes the deliberate and direct injuring of body tissue without suicidal intent for purposes not socially sanctioned (International Society for the Study of Self-injury;ISSS). Converging evidence suggests that the most common function of NSSI is to regulate negative emotional experiences (e.g., to stop bad feelings). In fact, self-injurers report more frequent and intense negative emotions, a reduction in negative emotions following a self-injurious act, and more emotion dysregulation than non-injurers. Taken together, research suggests that NSSI serves an emotion regulation function for individuals who struggle to regulate emotion. Therefore, careful examination of emotion dysregulation in NSSI could substantially improve knowledge about etiology, prevention, and treatment. Thus far, most of what we know about emotion in NSSI is based on self-report studies, which arguably provide only a crude understanding of emotional deficits. Research guided by an affective science framework could provide more nuanced and clinically useful information about emotion in NSSI. Specifically, emotion can be separated into multiple components, each of which represents a potential source of impairment in disorders characterized by emotion dysregulation. The present study will apply this framework to the study of emotion in NSSI by employing the eyeblink startle reflex, a well-validated physiological measure used to study emotional processing. More specifically, two possible sources of emotion dysregulation will be examined: the magnitude of the startle reflex will be measured 1) during the presentation of emotional and neutral pictures (i.e., to index emotional reactivity) and 2) several seconds following the presentation of these stimuli (i.e., to index return to emotional baseline). The time-course of emotional recovery following aversive stimuli will be further examined in a second study. The study protocol will be administered to a self-injuring and two non-injuring control samples (i.e., affectively distressed non-injurers and non-affectively distressed non-injurers).The long-term goal is to generate more precise knowledge regarding the source and nature of emotional dysregulation in NSSI that can guide the design and implementation of treatments. PUBLIC HEALTH RELEVANCE: Rates of NSSI are disproportionately high in adolescents and young adults. Other than Dialectical Behavior Therapy (DBT), which is an intensive, most often inpatient, treatment program for self-injurers with borderline personality disorder, there is currently no treatment for self-injury. This project represents the first step in a programmatic line of research to generate clinically useful models of emotion dysregulation in NSSI to guide the development of effective interventions.

DESCRIPTION (provided by applicant): The proposed research and training plan aims to advance our understanding of risk markers for suicidal behavior in adolescents, and to equip the applicant with the skills necessary to carry out independent longitudinal research in the areas of developmental psychopathology and suicide. There is an urgent need to identify ways to reduce rates of suicide among adolescents, and an important first step is to establish risk markers - or predictors - of suicide in this age group. The goal of the proposed research is to identify multipl behavioral and biological (psychophysiological) risk markers for suicidal behavior in adolescents. Importantly, these goals are also consistent with the National Institute of Mental Health (NIMH) Strategic Plan, which highlights the need for identifying biological and behavioral markers associated with clinically relevant problems. This goal will be achieved through the following specific aims: Aim 1. To examine the relation between two behavioral tasks for suicide (i.e., death/suicide IAT and suicide Stroop test) and suicidal behavior in adolescents. Aim 2. To examine the relation between reduced fear responding during suicide-related stimuli (psychophysiological measure) and suicidal behavior in adolescents. Aim 3. To examine additive and interactive associations between behavioral and psychophysiological predictors of suicidal behavior in adolescents. This work has the potential to better identify those adolescents at greatest suicide risk, who are in critical need of intervention. In line with state f the art methods used to diagnose physical conditions, this line of research aims ultimately to identify a short battery of tests that can be used to objectively assess risk for suicide in adolescents. These measures are ideal because they are brief, easily administered and scored, and thus could feasibly be used in an emergency department or inpatient setting to inform decisions about adolescents' admission and discharge from hospital care. Therefore, this program of research has the potential to significantly advance clinical science and to modernize the way the field assesses risk for suicidal behavior. The training plan in this application extends the applicant's previous research and clinical experiences in the following areas: developmental psychopathology, suicide, and longitudinal research design and analysis. In order to achieve these goals, the applicant has carefully assembled a team of sponsors and consultants to guide and support this project. Dr. Matthew Nock (sponsor) has expertise in suicide research and adolescent psychopathology. Dr. Ronald Dahl (consultant) is an expert in adolescent brain and pubertal development, as well as in early interventions. Finally, Dr. Terry Blumenthal has expertise in the startle reflex methodology - the physiological measure chosen for this project. In sum, the F32 training will advance the applicant's knowledge and expertise in three new areas and provide the foundation for a career as an independent clinical scientist. PUBLIC HEALTH RELEVANCE: Suicide is the third leading cause of death among youth ages 10 to 24 years, and alarmingly, the rates of suicide among this age group appear to be increasing. Although there is a critical need to identify adolescents at greatest risk for suicide, predicting suicidal behavior has proven difficult, and current strategies are insufficient. The goa of the current proposal is to identify behavioral and biological risk markers for suicidal behavior in adolescents in order to better detect those adolescents at greatest suicide risk, who are in urgent need of intervention.

PROJECT SUMMARY Suicide is the 2nd leading cause of death among adolescents, and, alarmingly, rates have continued to increase over the past decade. With the current dearth of empirically supported psychosocial interventions for adolescent suicidal behavior, there is a great need to identify processes underlying risk for this outcome. Interpersonal negative life events (NLEs) have been linked to short-term risk for suicidal behavior (i.e., suicide attempts and deaths). However, how or why these interpersonal NLEs confer risk is currently unclear. Understanding the moderators and mechanisms of the link between interpersonal NLEs and suicidal behavior is crucial in order to identify when adolescents are most at risk and to develop interventions that can target these mechanisms and reduce suicidal behavior during these periods of risk. Interpersonal NLEs may lead to suicidal behavior through their impact negative emotional states (e.g., agitation) and social connectedness, and further magnified by rejection sensitivity, emotion regulation difficulties, and sleep disturbance. Although past studies have found these constructs to be linked with suicidal behavior, this research is limited in three key ways: (1) Most prior studies have examined long time periods (months and years), which lack the temporal resolution to examine these mechanisms on the time scale in which they unfold (hours and days). We will intensively (over hours and days) examine how interpersonal NLEs relate to suicidal behavior. (2) Little is known about the impact of the social system, such as the family unit, and what key collaterals (e.g., parents) are observing in the short-term leading up to their adolescent?s suicidal behavior. By including parental reports, this study will reveal parents? awareness of their adolescents? suicide risk and potentially identify how parents can help them during these high-risk times. (3) Most past work has been insufficiently powered to examine links with suicidal behavior (instead focusing on suicidal thoughts). We propose to examine how and why interpersonal NLEs confer risk for suicidal behavior using smartphone-based ecological momentary assessment (EMA) and wearable sensors (i.e., wrist actigraphy) among 600 adolescents and their parents recruited from three diverse sites (Brown, Old Dominion, Rutgers) during the month after discharge from acute psychiatric care. We will address three aims: Aim 1. Examine how interpersonal (particularly familial and peer) NLEs increase risk for suicidal behavior through increased negative emotion and decreased social connectedness. Aim 2. Examine how rejection sensitivity moderates the link from interpersonal NLEs to negative emotionality/decreased social connectedness. Aim 3. Examine how sleep disturbance and emotion regulation difficulties moderate links from increased negative emotions and decreased social connectedness to suicidal behavior. This work will significantly advance understanding of proximal risk for suicidal behavior in youth and how the field assesses and treats suicidal adolescents.

PROJECT SUMMARY Suicidal thoughts and behaviors (STBs) are major public health concerns among adolescents. STBs have their initial onset during adolescence and rates increase drastically during this developmental period. To reduce risk for STBs in youth, research identifying modifiable targets for intervention is greatly needed. Sleep problems, and particularly insomnia?the most common sleep problem in adolescents, may be one such promising treatment target. Insomnia has been consistently and uniquely linked to STBs (i.e., beyond depression), is associated with STBs over the short term (e.g., days, weeks), and is very treatable. Cognitive behavioral therapy for insomnia (CBT-I) is a brief (4-8 session) intervention with proven efficacy (medium-large effects) for reducing insomnia severity in adolescents and adults. In addition, CBT-I has been found to reduce a range of co-occurring psychiatric symptoms in adolescents (e.g., depression) and suicide ideation in adults. Although CBT-I is an empirically supported treatment (EST) that is highly recommended for treating insomnia, many adolescents do not have access to this intervention. Digital (smartphone-based) versions of CBT-I (dCBT-I) have demonstrated efficacy similar to in-person CBT-I and are accessible to youth, especially during high-risk periods where the need for treatment is critical. One of the highest risk times for STBs is the three months after discharge from acute psychiatric care, which is also a time when youth may have limited access to ESTs (due to long waitlists, high costs, difficulty traveling to treatment). Digital versions of ESTs, like dCBT-I, are highly accessible and may fill this significant treatment gap. The goal of this project is to test a brief (6- session), empirically supported, and highly accessible version of dCBT-I, called SleepioTM, in suicidal adolescents with co-occurring insomnia during the high-risk post-hospitalization period. The SleepioTM program includes the primary components of in-person CBT-I in a highly accessible digital format (via smartphone app). Although CBT-I has demonstrated efficacy in adults and adolescents with insomnia and has been found to reduce suicide ideation among adults, it has not yet been tested with suicidal adolescents?a high-risk group that is typically excluded from CBT-I trials. The overall project goal will be achieved through the following aims: Examine the feasibility and acceptability of delivering dCBT-I, SleepioTM, to suicidal adolescents with co-occurring insomnia during the post-hospitalization period (Aim 1), and examine the effectiveness of dCBT-I for reducing insomnia severity (Aim 2; treatment target) and suicide (STB) outcomes (Aim 3; distal clinical outcome). In line with the National Action Alliance for Suicide Prevention priorities, this project addresses key questions: ?What interventions are effective [for reducing STB risk]? What prevents individuals from engaging in STBs?? The current project represents a unique opportunity to extend an EST to a high-risk population who are in critical need but have limited access to care. This program of research has the potential to significantly advance clinical science and to modernize the way the field treats suicidal youth.