Association between psychotic experiences and non-accidental self-injury: results from a nationally representative survey of adolescents
The association between psychotic experiences (PEs) and non-accidental self-injury (NASI; including self-harm and suicide attempts) is well established, although variables influencing this relationship have not been comprehensively examined. This study aimed to investigate (1) the cross-sectional PE–NASI association before and after adjustment for confounders, and (2) the individual contribution of each confounding and potentially mediating variable to the association.
A random sample of Australian adolescents aged 14–17 years (n = 1998) completed self-report questions regarding any self-harm, suicidality or PEs experienced in the past 12 months in 2013–2014 as part of the Young Minds Matter Survey, a national household survey. We conducted logistic regression analyses to investigate the association between NASI and PEs, after controlling for confounders (sociodemographics, substance use, and parental mental illness) as well as the influence of potential mediators (major depression, bullying, psychological distress, sleep, self-esteem, disordered eating behaviour, social isolation, and intervention factors).
Except for special messages, all PE subtypes (auditory and visual hallucinatory experiences [HEs], and two of the three delusional experiences [DEs]) were associated with NASI after adjustment for confounders (OR range: 2.60–5.21). Depression and psychological distress significantly influenced all PE–NASI associations, where depression appeared to fully explain the DE–NASI association, and partially attenuate the HE–NASI association. Variables such as parental mental illness, disordered eating behaviour, and social isolation had negligible effects in nearly all self-harm and attempted suicide models.
Adolescents reporting any PE in the past 12 months reported increased likelihood of NASI in the same time period and, auditory HEs in particular, were strongly and independently associated with self-harm and suicide attempts. These results highlight the importance of PEs as indicators of risk of self-injurious behaviour among Australian youth.
KeywordsPsychotic experiences Self-injurious behaviour Self-harm Suicide Adolescents
The authors wish to express their gratitude to the 6310 families who participated in the survey. The authors disclose receipt of the following financial support for the research, authorship, and/or publication of this article: The second Australian Child and Adolescent Survey of Mental Health and Wellbeing was funded by the Australian Government Department of Health. Emily Hielscher is supported by the Dr F and Mrs ME Zaccari Scholarship, Australia. Associate Professor James Scott is supported by a National Health and Medical Research Council Practitioner Fellowship Grant (Grant number 1105807). Professor Zubrick is supported by a Centre of Excellence grant from the Australian Research Council (CE140100027).
Compliance with ethical standards
Conflict of interest
The authors declare that they have no conflict of interest.
The research protocol for the study was approved by the Australian Government Department of Health Human Research Ethics Committee, and The University of Western Australia Human Research Ethics Committee. Therefore, the study was performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments. With permission from their parent or carer, the young person aged 14–17 years was given a copy of the Youth Information Brochure, reassured that their responses would be confidential and asked if they would like to participate. Consenting youth were given the use of a CASI tablet computer and, wherever possible, completed the questionnaire in private at the same time that the parent or carer was being interviewed in person.
- 1.Hielscher E, DeVylder JE, Saha S, Connell M, Scott JG (2017) Why are psychotic experiences associated with self-injurious thoughts and behaviours? A systematic review and critical appraisal of potential confounding and mediating factors. Psychol Med. https://doi.org/10.1017/S0033291717002677 CrossRefPubMedGoogle Scholar
- 8.Bromet EJ, Nock MK, Saha S, Lim CCW, Aguilar-Gaxiola S, Al-Hamzawi A, Alonso J, Borges G, Bruffaerts R, Degenhardt L, de Girolamo G, de Jonge P, Florescu S, Gureje O, Haro JM, He Y, Hu C, Karam EG, Kovess-Masfety V, Lee S, Lepine JP, Mneimneh Z, Navarro-Mateu F, Ojagbemi A, Posada-Villa J, Sampson NA, Scott KM, Stagnaro JC, Viana MC, Xavier M, Kessler RC, McGrath JJ, World Health Organization World Mental Health Survey C (2017) Association between psychotic experiences and subsequent suicidal thoughts and behaviors: a Cross-national analysis From the World Health Organization world mental health surveys. JAMA Psychiatry. https://doi.org/10.1001/jamapsychiatry.2017.2647 CrossRefPubMedPubMedCentralGoogle Scholar
- 9.Kelleher I, Corcoran P, Keeley H, Wigman JT, Devlin N, Ramsay H, Wasserman C, Carli V, Sarchiapone M, Hoven C, Wasserman D, Cannon M (2013) Psychotic symptoms and population risk for suicide attempt: a prospective cohort study. JAMA Psychiatry 70(9):940–948. https://doi.org/10.1001/jamapsychiatry.2013.140 CrossRefPubMedGoogle Scholar
- 11.Kelleher I, Lynch F, Harley M, Molloy C, Roddy S, Fitzpatrick C, Cannon M (2012) Psychotic symptoms in adolescence index risk for suicidal behavior: findings from 2 population-based case-control clinical interview studies. Arch Gen Psychiatry 69(12):1277–1283. https://doi.org/10.1001/archgenpsychiatry.2012.164 CrossRefPubMedGoogle Scholar
- 12.Kelleher I, Connor D, Clarke M, Devlin N, Harley M, Cannon M (2012) Prevalence of psychotic symptoms in childhood and adolescence: a systematic review and metaanalysis of population-based studies. Psychol Med 9:1–7Google Scholar
- 15.Martin G, Thomas H, Andrews T, Hasking P, Scott JG (2015) Psychotic experiences and psychological distress predict contemporaneous and future non-suicidal self-injury and suicide attempts in a sample of Australian school-based adolescents. Psychol Med 45(2):429–437. https://doi.org/10.1017/S0033291714001615 CrossRefPubMedGoogle Scholar
- 16.Nishida A, Tanii H, Nishimura Y, Kajiki N, Inoue K, Okada M, Sasaki T, Okazaki Y (2008) Associations between psychotic-like experiences and mental health status and other psychopathologies among Japanese early teens. Schizophr Res 99(1–3):125–133. https://doi.org/10.1016/j.schres.2007.11.038 CrossRefPubMedGoogle Scholar
- 17.Nishida A, Shimodera S, Sasaki T, Richards M, Hatch SL, Yamasaki S, Usami S, Ando S, Asukai N, Okazaki Y (2014) Risk for suicidal problems in poor-help-seeking adolescents with psychotic-like experiences: findings from a cross-sectional survey of 16,131 adolescents. Schizophr Res 159(2–3):257–262. https://doi.org/10.1016/j.schres.2014.09.030 CrossRefPubMedGoogle Scholar
- 18.Polanczyk G (2010) Etiological and clinical features of childhood psychotic symptoms. Arch Gen PsychiatryGoogle Scholar
- 19.Sullivan SA, Lewis G, Gunnell D, Cannon M, Mars B, Zammit S (2015) The longitudinal association between psychotic experiences, depression and suicidal behaviour in a population sample of adolescents. Soc Psychiatry Psychiatr Epidemiol 50(12):1809–1817. https://doi.org/10.1007/s00127-015-1086-2 CrossRefPubMedPubMedCentralGoogle Scholar
- 20.Nishida A, Sasaki T, Nishimura Y, Tanii H, Hara N, Inoue K, Yamada T, Takami T, Shimodera S, Itokawa M, Asukai N, Okazaki Y (2010) Psychotic-like experiences are associated with suicidal feelings and deliberate self-harm behaviors in adolescents aged 12–15 years. Acta Psychiatr Scand 121(4):301–307. https://doi.org/10.1111/j.1600-0447.2009.01439.x CrossRefPubMedGoogle Scholar
- 21.Cederlöf M, Kuja-Halkola R, Larsson H, Sjolander A, Ostberg P, Lundstrom S, Kelleher I, Lichtenstein P (2016) A longitudinal study of adolescent psychotic experiences and later development of substance use disorder and suicidal behavior. Schizophr Res. https://doi.org/10.1016/j.schres.2016.08.029 CrossRefPubMedGoogle Scholar
- 22.Wickham S, Taylor P, Shevlin M, Bentall RP (2014) The impact of social deprivation on paranoia, hallucinations, mania and depression: the role of discrimination social support, stress and trust. PLoS One 9(8):e105140. https://doi.org/10.1371/journal.pone.0105140 CrossRefPubMedPubMedCentralGoogle Scholar
- 26.Lawrence D, Hafekost J, Johnson SE, Saw S, Buckingham WJ, Sawyer MG, Ainley J, Zubrick SR (2016) Key findings from the second Australian child and adolescent survey of mental health and wellbeing. Aust N Z J Psychiatry 50(9):876–886. https://doi.org/10.1177/0004867415617836 CrossRefPubMedGoogle Scholar
- 27.Hafekost J, Lawrence D, Boterhoven de Haan K, Johnson SE, Saw S, Buckingham WJ, Sawyer MG, Ainley J, Zubrick SR (2016) Methodology of young minds matter: the second Australian child and adolescent survey of mental health and wellbeing. Aust N Z J Psychiatry 50(9):866–875. https://doi.org/10.1177/0004867415622270 CrossRefPubMedGoogle Scholar
- 29.Hielscher E, Connell M, Lawrence D, Zubrick SR, Hafekost J, Scott J (2018) Prevalence and correlates of psychotic experiences in a nationally representative sample of Australian adolescents. Aust N Z J Psychiatry (advanced online publication) Google Scholar
- 30.Platt S, Bile-Brahe U, Kerkhof A, Schmidtke A, Bjerke T, Crepet P, De Leo D, Aring C, Lonnqvist J, Michel K, Philippe A, Pommereau X, Querejeta I, Salander-Renberg E, Temesvary B, Wasserman D, Sampaio FJ (1992) Parasuicide in Europe: the WHO/EURO multicentre study on parasuicide. I. Introduction and preliminary analysis for 1989. Acta Psychiatr Scand 85:97–104CrossRefGoogle Scholar
- 32.Zubrick SR, Hafekost J, Johnson SE, Lawrence D, Saw S, Sawyer M, Ainley J, Buckingham WJ (2016) Suicidal behaviours: prevalence estimates from the second Australian Child and adolescent survey of mental health and wellbeing. Aust N Z J Psychiatry 50(9):899–910. https://doi.org/10.1177/0004867415622563 CrossRefPubMedGoogle Scholar
- 33.Zubrick SR, Hafekost J, Johnson SE, Lawrence D, Saw S, Sawyer M, Ainley J, Buckingham WJ (2016) Self-harm: prevalence estimates from the second australian child and adolescent survey of mental health and wellbeing. Aust N Z J Psychiatry 50(9):911–921. https://doi.org/10.1177/0004867415617837 CrossRefPubMedGoogle Scholar
- 34.Hafekost K, Boterhoven de Haan K, Lawrence D, Sawyer MG, Zubrick SR (2017) Validation of the adolescent self-esteem questionnaire: technical report. Perth, AustraliaGoogle Scholar
- 38.Wolter KM (2007) Introduction to variance estimation, 2nd edn. Springer, New YorkGoogle Scholar
- 39.Firth D (1995) Bias reduction of maximum likelihood estimates. Biometrika 82(3):667Google Scholar
- 40.Rothman KJ, Greenland S (1998) Modern epidemiology. Lippincott-Raven, PhiladelphiaGoogle Scholar
- 42.Wilson C, Secker J (2015) Validation of the Social Inclusion Scale with students. Cogitatio 3(4):52–62Google Scholar
- 44.van Os J, Linscott RJ, Myin-Germeys I, Delespaul P, Krabbendam L (2009) A systematic review and meta-analysis of the psychosis continuum: evidence for a psychosis proneness-persistence-impairment model of psychotic disorder. Psychol Med 39(2):179–195. https://doi.org/10.1017/S0033291708003814 CrossRefPubMedGoogle Scholar
- 47.Norman RE, Byambaa M, De R, Butchart A, Scott J, Vos T (2012) The long-term health consequences of child physical abuse, emotional abuse, and neglect: a systematic review and meta-analysis. PLoS Med 9(11):e1001349. https://doi.org/10.1371/journal.pmed.1001349 CrossRefPubMedPubMedCentralGoogle Scholar