Mentalization in female adolescents with non-suicidal self-injury and alexithymic and depressive features in their parents

Abstract

Background:

Non-suicidal self-injury (NSSI) is a condition with debilitating consequences. We aimed to assess the mentalization skills of female adolescents with NSSI and parents who showed alexithymia and depressive symptoms.

Method:

Ours was a case-control study. Thirty adolescents with NSSI were recruited into the case group, 31 adolescents were recruited into the control group. Reading the Mind in the Eyes Test (RMET) and the Kiddie Schedule for Affective Disorders and Schizophrenia for School-Age Children – Present and Lifetime Version (K-SADS-PL) were applied. The Inventory of Statements about Self-Injury was used. The Toronto Alexithymia Scale (TAS-20) and Beck Depression Inventory (BDI) were given to parents.

Results:

There were no significant differences between two groups for RMET and parental TAS-20 scores. Maternal BDI scores were found to be significantly higher in the NSSI group. There were no significant differences for paternal BDI. RMET scores correlated negatively with maternal BDI scores. Major depression was found to be the most common diagnosis in the NSSI group.

Conclusion:

Because maternal depressive features seem to be related to NSSI, a detailed psychiatric examination of mothers should be carried out. Studies with larger samples or different designs are needed for a better understanding of the mentalization in NSSI.

Keywords

Adolescents alexithymia mentalization non-suicidal self-injury parental depression

Introduction

Non-suicidal self-injury (NSSI) is defined as the deliberate, self-inflicted damage of the body’s tissues without suicidal intent, and for purposes not socially or culturally sanctioned (International Society for the Study of Self-injury, 2018). Different prevalence studies with varying designs give a range of NSSI incidence of 14% to 46.5% (Briere & Gil, 1998; Lloyd-Richardson et al., 2007; Muehlenkamp et al., 2009; Somer et al., 2015). In a study of the Turkish population, the prevalence of NSSI was found to be 21.4% (Zoroglu et al., 2003). NSSI risk factors include cluster B personality disorders, hopelessness, female gender, dysfunctional relationships, bullying, and non-heterosexual orientation. Parental neglect, emotional abuse, and witnessing domestic violence are also highly associated with NSSI (Brown & Plener, 2017).

Despite having detrimental effects on the psychological, medical, and social aspects of a person and his/her family, previous studies have reported that people who engage in self-harm do so for affect regulation, to exert interpersonal influence, as a means of self-punishment, dissociation, sensation-seeking, averting suicide, maintaining or exploring boundaries, or expressing and coping with sexuality (Edmondson et al., 2016).

Alexithymia is described as the inability to describe and identify emotional experiences, the inability to distinguish between emotions and bodily sensations, and externally oriented thinking (Taylor et al., 1999). Alexithymia is linked to many psychiatric diagnoses, including autism spectrum disorders, post-traumatic stress disorder, eating disorders, major depression, substance use disorders, and anxiety disorders. One study has shown that NSSI is also related to alexithymia (Lüdtke et al., 2016).

The theory of mind is the ability to impute mental states for oneself and others (Premack & Woodruff, 1978). The Reading Mind in the Eyes Test is one of the tests that evaluates a person’s theory of mind capabilities; it also includes emotional recognition in the form of decoding mental states, which also called mentalization (Baron-Cohen, Wheelwright, Hill, et al., 2001). People with major depression and cluster B personality disorders which are known to have increased NSSI could also have impaired theory of mind skills (Richman & Unoka, 2015). Alexithymia and impaired mentalization skills seem to be closely related. The former could be called a deficit in mentalizing own mental states and emotions (Riem et al., 2018). In this paper, we also explore the mental state decoding skills of adolescents with NSSI.

This study aims to explore both adolescents’ and their parents’ emotional recognition capabilities. We hypothesize that impaired parental emotional recognition or responsivity could impair the patient’s affective regulation, leading to using NSSI for affective regulation purposes. These individuals struggle to deal with negative emotions, so to relieve or decrease these feelings, they resort to NSSI (Favazza, 1992; Gratz, 2003). We expected to find: (a) adolescents with NSSI would have lower Reading the Mind in the Eyes Test scores, (b) parents of these adolescents would have higher Beck Depression Inventory scores and higher Toronto Alexithymia Scale scores, and (c) parental Beck Depression Inventory and parental Toronto Alexithymia Scale scores would be negatively correlated with adolescents’ Reading the Mind in the Eyes test scores.

Method

Participants

Our sample consisted of 61 adolescents; 30 of them were in the NSSI group, and the remaining 31 served as the control group. The inclusion criteria for this study were: age 12 to 18 years, agreeing to participate, and willing to answer questions after the study was explained. Both adolescents and their biological parents needed to agree and give consent to participate in the study. For the NSSI group, admission to an outpatient child or adolescent psychiatry clinic with a history for non-suicidal self-injury was required. Adolescents and/or their biological parents who could not complete the forms or answer the questions were excluded from this study. All diagnosed mental health problems in the control group were excluded. People with acute psychotic disorders, acute manic episode, and autism spectrum disorders were also excluded from the NSSI group. Any recruited participant with an intellectual disability was excluded. People with these disorders could have failed to complete the interview, and they were expected to be unable to fill out expected scales.

Instruments

Sociodemographic data form

The researchers prepared a sociodemographic data form and used it to evaluate the characteristics of patients. This form consisted of questions about adolescents’ age and education, their parents’ age, education, monthly income, parental occupation, and psychiatric histories. This was completed by the interviewer during the interview process.

Inventory of Statements About Self-Injury (ISAS)

The Inventory of Statements About Self-Injury (ISAS) was developed by Klonsky and Glenn (2009) for describing self-injury and evaluating its functions (Klonsky & Glenn, 2009). The Turkish version of the ISAS’ validity and reliability was confirmed (Bildik et al., 2013). It comprises of two sections; the first assesses the frequency of several different self-injury types, while the second assesses 13 intrapersonal and interpersonal functions by rating each function as ‘0-not relevant’, ‘1-somewhat relevant’, or ‘2-very relevant’. The scale can be completed in approximately 15 minutes. The first and second parts have Cronbach’s α coefficients of 0.79 and 0.93, respectively.

Toronto Alexithymia Scale (TAS-20)

The Toronto Alexithymia Scale (TAS-20) scale is used for self-reporting and assessing alexithymia (Bagby et al., 1994). A Turkish version with validity and reliability assessments is used in this study (Sayar et al., 2001). A 5-point Likert-type rating (1-completely disagree, through 5-completely agree) was used, with some items rated negatively. It consisted of three subscales: (a) difficulty describing feelings, (b) difficulty identifying feelings, and (c) externally oriented thinking. The Turkish version has a cut-off point where scores below 51 were deemed non-alexithymic and those over 59 indicated alexithymia. The Cronbach α for the total scale was found to be 0.78 (Güleç & Yenel, n.d.). It can be completed in approximately 15 minutes.

Beck Depression Inventory

Developed by Beck et al. (1961) with Turkish reliability by Hisli et al. (1989), the Beck Depression Inventory is used for evaluating the severity of depressive symptoms. This self-reported survey consists of 21 questions and asks about the patient’s last week. It takes approximately 10 minutes to complete. Every question has four answers, with scores ranging from 0 to 3. Scores higher than 17 predict a treatment need for depression. This inventory’s Cronbach’s α coefficients for psychiatric and non-psychiatric populations were found to be α = 0.86 and α = 0.81, respectively.

Reading Mind in the Eyes Test (RMET)

Also called ‘The Eyes Test’, the Reading Mind in the Eyes Test (RMET) was developed by Baron-Cohen, Wheelwright, Hill, et al. (2001) and Baron-Cohen, Wheelwright, Spong, et al. (2001) first for adults, with a child form developed later based on the adult version. The Turkish validity and reliability study was done by Girli et al. (2014) The instrument is used for evaluating a participant’s ability to assess several mental states, including emotion recognition. It consists of 28 pictures with four different mental states written around them. Participants are asked to choose which one applies. As the participant chooses, we can assess how well they can put themselves into the minds of others and tune in to their mental state, which is referred to as ‘mentalizing’. For each true answer, one point is given. Higher scores mean better mentalizing skills. It takes about 30 minutes to complete this test. The test’s Cronbach’s α is 0.72 (Girli, 2014).

The Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version (K-SADS-PL)

A semi-structured interview, the Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version (K-SADS-PL), was developed by Kaufman et al. (1997). The Turkish version of this interview is used in the present study (Gökler et al., 2004) and delivered by a trained interviewer. It assesses 32 DSM-IV Axis 1 diagnoses and consists of three parts. The introductory interview is used to build rapport, gather demographic data, functioning data, and complaints. The second part is the screening interview, with 82 symptoms and 20 different diagnostic areas. This part is used for screening purposes. The last part is the diagnostic supplements section. There are five diagnostic supplements (1-affective disorders; 2-psychotic disorders; 3-anxiety disorders; 4-behavioral disorders; and 5-substance abuse, eating, and tic disorders). Each one is completed if the screening interview refers the interviewee to the said supplement. A K-SADS-PL interview takes about 1 hour to complete, for both parents and children.

Procedure

This study was approved by the ethics committee of the Bakırköy Prof. Dr. Mazhar Osman Mental Health and Neurology Training and Research Hospital. Beginning in July 2017, telephone numbers were taken for all patients who applied to the outpatient child and adolescent psychiatry clinic of our hospital reporting self-harm. Patients who met the inclusion criteria were called for an appointment after the first examination. Verbal information was given before the interview, and then written informed consent was obtained from the interviewed patient and their biological parents. Interviews were conducted with the people who gave consent and agreed to an interview. Because there were only three male patients recruited during the study’s recruitment phase of the NSSI group, we excluded them from the study, to reduce statistical errors related to low count. In all, 30 patients were included in the study. A healthy control group was formed of adolescents of similar age, gender, and socioeconomic status.

Both groups were given a sociodemographic data form, to gather their sociodemographic data, and the ISAS, for qualitative and causal specifications about self-harm. Their parents were given the TAS and Beck Depression Inventory.

After the forms were collected, a K-SADS-PL structured interview was performed by a certified clinician for the collection of comorbidity profiles. The K-SADS-PL was also used for assessing exclusion criteria. To evaluate adolescents’ theory of mind skills, the RMET was performed by a clinician.

Data analyses

SPSS (Statistical Package for Social Sciences) 25, by IBM, was used for statistical analyses. Pearson’s chi-square test was applied to compare categorical values. Fisher’s Exact Test or the Fisher–Freeman–Halton test was used in situations where one variable was under count 5. The Kolmogorov–Smirnoff and Wilkinson–Shapiro tests were used to evaluate the normal distribution for continuous variables. Either independent sample t-tests or the Mann–Whitney U test was used for comparing continuous variables, depending on their distribution. Pearson’s R test was used for correlation analyses.

Results

This study’s sample consisted of 61 participants ranging in age from 13 to 17 years. Thirty of them were in the self-harming case group, while the other 31 were in the control group. The mean ages were 15.47 ± 1.22 in the NSSI group and 15.29 in the control group. Sociodemographic data of the participants and their statistics are shown in Table 1. The differences between the NSSI and the control groups for school status and smoking were significant.

Table 1.

Age, siblings, school status, family monthly income, BMI, and smoking.

		NSSI group	Healthy control group	Statistics
Age		15.47 ± 1.22	15.29 ± 1.24	p = .58
Sibling count (%)	No sibling	1 (3.3)	2 (6.5)	p = .77
	One sibling	16 (53.3)	14 (45.2)
	Two or more siblings	13 (43.3)	15 (48.4)
School status (%)	Grade repetition	6 (21)	0 (0)	p = .009*
Monthly income (%)	Low	9 (37.5)	10 (32.3)	p = .23
	Middle	15 (62.5)	17 (54.8)
	High	0 (0)	4 (12.9)
Body Mass Index		23.91 ± 6.19	21.13 ± 2.97	p = .19
Smoking (%)		8 (26.7)	2 (6.5)	p = .04*

Note. Student’s t test, Fisher-Freeman Halton exact, Fisher’s exact, Mann-Whitney U.

p < .05.

Participants’ mental state decoding skills were assessed by applying the RMET. Test scores ranged from 13 to 27 across the entire sample. Normality tests were applied to the scores, and the scores appeared to be distributed normally in both groups. The mean scores on the RMET were 19 ± 3 in the NSSI group and 21 ± 3 in the control group. There were no significant differences between the groups for RMET scores when compared with the student’s t-test (p = .118).

Caregivers were given the Beck Depression Inventory to assess depressive symptoms and the Toronto Alexithymia Scale to assess alexithymia (Table 2). Mothers’ and fathers’ scores for the BDI and TAS, between the NSSI and control groups, were compared separately. Maternal TAS scores ranged from 32 to 83 in the whole sample, and paternal scores ranged from 28 to 63 in the whole sample. There were no significant differences between the groups for maternal or paternal scores. For the BDI, maternal scores ranged from 0 to 37, while paternal scores ranged from 1 to 19. Maternal BDI scores differed significantly between the NSSI and the control groups.

Table 2.

Maternal and paternal BDI – TAS scores.

			The NSSI group	The Control group	Statistics
Maternal scales	Toronto Alexithymia scale	TAS-A	14 ± 6	15 ± 6	p = .69
		TAS-B	13 ± 4	12 ± 3	p = .32
		TAS-C	22 ± 4	22 ± 3	p = .88
		TAS total	49 ± 11	48 ± 8	p = .83
	Beck depression inventory		14.20 ± 6.36	9.66 ± 7.94	p = .002*
Paternal scales	Toronto Alexithymia scale	TAS-A	15 ± 6	13 ± 5	p = .34
		TAS-B	13 ± 5	10 ± 2	p = .11
		TAS-C	21 ± 4	20 ± 4	p = .51
		TAS total	49 ± 11	42 ± 9	p = .06
	Beck depression inventory		9.70 ± 6.34	8.13 ± 6.01	p = .62

Note. Mann-Whitney U.

p < .05.

Three people in the NSSI group had a mother who also had a history of self-harm, and one person had a father with a history of self-harm. No members of the control group had any parental history of self-harm. The differences were not significant among the mothers and fathers (p = .11 and p = .49, respectively). For suicidal attempts, four cases in the NSSI group had a mother with a history of a suicide attempt, but none of their fathers had a history of suicide attempt. In the control group, only one father had a history of a suicide attempt. For both mothers and fathers, there were no significant differences for suicide attempts (p = .053 and p = 1.00, respectively).

According to the K-SADS-PL interview results in the NSSI group, we found major depression to be the most common diagnosis with 50% (n = 15) of the NSSI group. Oppositional defiant disorder (n = 10) and attention deficit hyperactivity disorder (n = 8) were the second and third most common diagnoses, respectively. Only 33% (n = 10) of the NSSI group presented with one diagnosis, the rest of them presented with two to five diagnoses.

Self-cutting was the most common self-harming method, with 62.1%. Other common self-harming methods in the NSSI group were wound picking and banging, with 53.3% and 50%, respectively, reporting these acts. Descriptions and functions of self-harm are included in Tables 3 and 4.

Table 3.

ISAS descriptives.

	n	%
First self harm age
<11	3	11.5
12	4	15.4
13	5	19.2
14	10	38.5
15	2	7.7
16	2	7.7
Feeling pain
Yes	7	23.3
Sometimes	7	23.3
No	16	53.3
Being alone
Yes	25	83.3
Sometimes	5	16.7
Time between urge and self-injury
<1 hour	18	62.1
>1 hour	11	37.9
Wanting to stop self harm
Yes	19	63.3
No	11	36.7

Table 4.

Self-harm functions.

	Mean ± SD	Min–Max (Median)
Affect regulation	4.86 ± 1.43	2–6 (5)
Marking distress	3.93 ± 2.02	0–6 (4)
Self-punishment	3.38 ± 1.82	0–6 (3)
Anti-dissociation	2.55 ± 2.20	0–6 (2)
Revenge	2.55 ± 1.76	0–6 (2)
Anti-suicide	2.38 ± 1.82	0–6 (2)
Self-care	2.14 ± 1.30	0–4 (2)
Toughness	1.93 ± 1.89	0–6 (2)
Interpersonal boundaries	1.76 ± 1.60	0–5 (2)
Interpersonal influence	1.38 ± 1.37	0–6 (1)
Autonomy	1.24 ± 1.72	0–6 (0)
Sensation seeking	1.07 ± 1.36	0–5 (1)
Peer bonding	0.07 ± 0.37	0–2 (0)

We used Pearson’s R correlation analysis to investigate the relationship between the RMET and parental scales in the sample (Table 5). In the NSSI group, we also used Pearson’s R correlation analysis for ISAS affective regulation scores, RMET, Parental BDI, and TAS-20. These revealed no significant relationships.

Table 5.

Correlation analysis between RMET and parent scales.

	Pearson’s R	p
RMET
Maternal TAS-20	−0.229	p = .095
Maternal BDI	−0.365	p = .007**
Paternal TAS-20	−0.357	p = .134
Paternal BDI	−0.261	p = .295

p < .05. **p < .01. ***p < .001.

Discussion

In this study, we examined whether an adolescent’s mentalization skills, parental alexithymia, and parental depression had a role in adolescents’ self-harm. We found no significant differences between the NSSI group and the control group, for RMET scores. According to these findings, self-harm does not predict lower mentalization skills. This result was inconsistent with Laghi et al.’s (2016) findings. They found mentalization skills were impaired in patients with NSSI, compared to the controls. (Laghi et al., 2016). The differences between the studies’ results could have been rooted in their differing study designs. We used RMET to assess mentalization skills, while Laghi et al. used the Theory of Mind Assessment Scale (TH.o.m.a.s). The RMET is more focused on decoding and putting oneself in the shown mental state (Baron-Cohen, Wheelwright, Spong, et al., 2001), while the TH.o.m.a.s is a semi-structured interview that assesses the subject’s understanding of mental states in given situations (Bosco et al., 2009). Further studies are needed to examine different aspects of mentalization in relation to NSSI.

Many previous studies have reported that self-harm are mostly seen in conjunction with major depressive disorder or borderline personality disorder (Ayodeji et al., 2015; Kemperman et al., 1997). Consistent with the literature, we also found that major depressive disorder was the most diagnosed mental disease among adolescents with self-harm. Our study included no assessments for borderline personality disorder. Some researchers have found that subjects with major depressive disorders also have impaired mentalization skills (Richman & Unoka, 2015). Our results were inconsistent with these findings. Differences between the reports in the literature and our study could be explained by the age difference of the sampled populations. In contrast to most studies done on this subject, which used an adult population, we used an adolescent population. Our subjects’ shorter duration of major depressive disorder could be less likely to have impaired their mentalization skills. Further research is needed on how major depressive disorder in adolescents affects their mentalization skills.

Maternal BDI scores were higher in our NSSI group compared to our control group. There was no significant difference related to paternal BDI scores. In the literature, some studies report that parental depression and self-harm are related to one another (Gromatsky et al., 2017; Hankin & Abela, 2011), while others found that there was no relationship (Cox et al., 2012). Similar to our study, in studies that state maternal depression and self-harm are related, the relationship between paternal depression and self-harm that was found weak (Gromatsky et al., 2017). We found no significant differences between the NSSI and the control groups for parental self-harm or suicide attempts. A study by Geulayov et al. (2014) found that mothers’ self-harm and suicide attempts were more significant in terms of adolescents’ suicide attempts, but the same relationship was not maintained in adolescents’ self-harm. Our sample size was small for assessing this relationship.

We found that maternal BDI scores were negatively correlated with adolescent RMET scores. To our knowledge, there have been no studies conducted on children whose mothers have been diagnosed with depression. One study conducted on adults found that mentalization skills tend to be higher in people with a history of depression in their mothers (Harkness et al., 2011). Maternal depression could have an effect on a child’s mentalization skills development. It is possible that, with decreased reciprocal and affective relationships, a child’s mentalization skills will be affected. More research is needed on this subject.

We found no significant differences in parental TAS-20 scores between the NSSI and the control groups. To our knowledge, our study is the first to focus on parental alexithymia in self-harm, so we could not find any study for comparison. A study by Tarantino et al. (2018) found that maternal alexithymia is related to insecure attachment. A study done by Yürümez et al. (2014) found that maternal alexithymia affected the quality of mother–infant relationships negatively. Our results indicated there is no direct influence of maternal or paternal alexithymia for self-harm, but more studies with larger samples are needed to confirm this conclusion.

Consistent with the literature, smoking was found to be more common in the NSSI group than control group (Brunner et al., 2007). Similar to self-harm, smoking, alcohol, and illegal substances are also reported to be used for affective regulation (Brunner et al., 2007; Nock et al., 2006), and they can be used as a means to self-harm (Brunner et al., 2007).

The greatest limitation on our study came from the use of the RMET child version. There are two versions of this test, one each for adults and children (Baron-Cohen, Wheelwright, Hill, et al., 2001, Baron-Cohen, Wheelwright, Spong, et al. 2001). The main difference between them is that the child version requires less vocabulary knowledge, and the adult version features more complex mental states. Because there is no version designed specifically for our sample’s age range, we used the child version. This could have resulted in inflated results by lesser knowledge and simpler decoding skills would be needed. Another limitation of our study was the lack of patients with a substance abuse disorder. Our hospital operates a different center for patients with substance abuse disorders, so these patients were not included in our study. For this reason, we did not need to account for psychoactive substances’ effects on cognitive skills. Another limitation was our small sample size; this could have resulted in the study being too underpowered for smaller differences.

The strength of our study comes from its evaluation of both patients and caregivers in one sitting. In this setting, we had the opportunity to observe not only the adolescents’ and their parents’ mentalization and emotional recognition skills, but also their effects on each other. Parents are usually one of the closest support systems for adolescents. In our study, one thing that caught our attention is parents were generally late to find out that adolescent was struggling. They weren’t there to support the adolescent with their emotion regulation problems. With a similar setting to our study, more studies are needed to explore and detail this problem. Another strength is that our study is one of the first to assess in a clinical setting the mentalization skills of adolescents with self-harm.

In conclusion, NSSI is a condition that results in many physical and mental comorbidities. We wanted to examine the effect of the family’s and adolescents’ mentalization skills on this process. We found that the depressive features of both the child and the mother might be related to NSSI, so when an adolescent with self-harm comes for treatment, a detailed psychiatric evaluation should be made for both the adolescent and his or her mother. Although we found no significant relationships between the patient’s mentalization skills, parental alexithymia, and the NSSI, studies with a larger sample size or different designs could find different results.

Footnotes

Author contributions

All authors share responsibility for the final version of the work. All authors had contributions to conception, design, drafting and final approval of the work. And they agree to be accountable for all aspects of the work.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Mehmet Tekden

Author biographies

Mehmet Tekden is a child and adolescent psychiatrist at Bakirkoy Prof. Dr. Mazhar Osman Mental Health and Nervous Disorders Training and Research Hospital . His main study areas include substance abuse and affective disorders.

Ali Güven Kılıçoğlu is an associate professor of child and adolescent psychiatry and head of the child and adolescent psychiatry department at Bezmialem Vakıf Üniversitesi Faculty of Medicine. His main study areas include attention deficit hyperactivity disorder, sluggish cognitive tempo and bipolar disorders.

Caner Mutlu is an associate professor of child and adolescent psychiatry at Bakirkoy Prof. Dr. Mazhar Osman Mental Health and Nervous Disorders Training and Research Hospital. He mainly studies on adolescent mental health.

Gül Karaçetin is a professor of child and adolescent psychiatry and head of the child and adolescent psychiatry department at Bakirkoy Prof. Dr. Mazhar Osman Mental Health and Nervous Disorders Training and Research Hospital. Her research areas include psychotic disorders, depression, suicide and cognitive behavioral therapy.

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