Risk-Sensitive Decision-Making and Self-Harm in Youth Bipolar Disorder

Mikaela K. Dimick, PhD; Alysha A. Sultan, PhD; Kody G. Kennedy, PhD; Sakina J. Rizvi, PhD; Erika E. Forbes, PhD; Mark Sinyor, MD; Roger S. McIntyre, MD; Eric A. Youngstrom, PhD; Benjamin I. Goldstein, MD, PhD

J Clin Psychiatry 2023;84(5):22m14693

ABSTRACT

Background: Youth with bipolar disorder (BD) are at high risk for suicide and have high rates of self-harm, which includes both suicide attempts and non-suicidal self-injury. Greater risk-taking has been associated with suicide attempts in youth with major depression, although there are no studies examining the relationship between risk-related decision-making and self-harm in youth with BD. We aimed to examine the association of suicide risk with risk-sensitive decision-making in a controlled sample of youth with BD.

Methods: Eighty-one youth with BD (based on DSM-IV criteria; 52 youth with a history of self-harm [BD_SH+]; 29 without a history of self-harm [BD_SH–]) and 82 age- and sex-matched control youth aged 13–20 years were recruited between 2012 and 2020. Decision-making and risk-taking performance were assessed via the Cambridge Gambling Task within the Cambridge Neuropsychological Test Automated Battery (CANTAB). General linear models were used to examine differences between groups with control for age, sex, and IQ.

Results: There was a significant difference in the overall proportion of points bet (F_2,157 = 3.87, P = .02, η² = 0.23) such that BD_SH– youth performed better than both BD_SH+ (P = .02) and control youth (P = .04). Mean latency was significant (F_3,156 = 4.12, P = .017, η² = 0.03), with BD_SH– youth deliberating longer than controls (P = .03). Risk-taking significantly differed between groups (F_2,157 = 3.83, P = .02, η² = 0.23), with BD_SH– youth showing greater self-control compared to BD_SH+ (P = .01) and control youth (P = .01).

Conclusions: BD_SH– youth had greater self-control and lower risk-taking. We speculate this finding may be reflective of a compensatory process among BD_SH– youth serving a protective role in suicide risk. Future longitudinal studies are needed to examine the temporal association of neurocognition and self-harm among youth with BD.

J Clin Psychiatry 2023;84(5):22m14693

Author affiliations are listed at the end of this article.

Continue Reading...

Did you know members enjoy unlimited free PDF downloads as part of their subscription? Subscribe today for instant access to this article and our entire library in your preferred format. Alternatively, you can purchase the PDF of this article individually.

Subscribe Now

Already a member? Login

Purchase PDF for $40

Members enjoy free PDF downloads on all articles. Join today

References (55)

Cha CB, Franz PJ, M Guzmán E, et al. Annual research review: suicide among youth - epidemiology, (potential) etiology, and treatment. J Child Psychol Psychiatry. 2018;59(4):460–482. PubMed CrossRef
De Crescenzo F, Serra G, Maisto F, et al. Suicide attempts in juvenile bipolar versus major depressive disorders: systematic review and meta-analysis. J Am Acad Child Adolesc Psychiatry. 2017;56(10):825–831.e3. PubMed CrossRef
Goldstein TR, Birmaher B, Axelson D, et al. History of suicide attempts in pediatric bipolar disorder: factors associated with increased risk. Bipolar Disord. 2005;7(6):525–535. PubMed CrossRef
Wilkinson P, Kelvin R, Roberts C, et al. Clinical and psychosocial predictors of suicide attempts and nonsuicidal self-injury in the Adolescent Depression Antidepressants and Psychotherapy Trial (ADAPT). Am J Psychiatry. 2011;168(5):495–501. PubMed CrossRef
Asarnow JR, Porta G, Spirito A, et al. Suicide attempts and nonsuicidal self-injury in the treatment of resistant depression in adolescents: findings from the TORDIA study. J Am Acad Child Adolesc Psychiatry. 2011;50(8):772–781. PubMed CrossRef
Perrain R, Dardennes R, Jollant F. Risky decision-making in suicide attempters, and the choice of a violent suicidal means: an updated meta-analysis. J Affect Disord. 2021;280(Pt A):241–249. PubMed CrossRef
Sastre-Buades A, Alacreu-Crespo A, Courtet P, et al. Decision-making in suicidal behavior: a systematic review and meta-analysis. Neurosci Biobehav Rev. 2021;131:642–662. PubMed CrossRef
Sheftall AH, Davidson DJ, McBee-Strayer SM, et al. Decision-making in adolescents with suicidal ideation: a case-control study. Psychiatry Res. 2015;228(3):928–931. PubMed CrossRef
Pan L, Segreti A, Almeida J, et al. Preserved hippocampal function during learning in the context of risk in adolescent suicide attempt. Psychiatry Res. 2013;211(2):112–118. PubMed CrossRef
Oldershaw A, Grima E, Jollant F, et al. Decision making and problem solving in adolescents who deliberately self-harm. Psychol Med. 2009;39(1):95–104. PubMed CrossRef
Bridge JA, McBee-Strayer SM, Cannon EA, et al. Impaired decision making in adolescent suicide attempters. J Am Acad Child Adolesc Psychiatry. 2012;51(4):394–403. PubMed CrossRef
Ackerman JP, McBee-Strayer SM, Mendoza K, et al. Risk-sensitive decision-making deficit in adolescent suicide attempters. J Child Adolesc Psychopharmacol. 2015;25(2):109–113. PubMed CrossRef
Gifuni AJ, Perret LC, Lacourse E, et al. Decision-making and cognitive control in adolescent suicidal behaviors: a qualitative systematic review of the literature. Eur Child Adolesc Psychiatry. 2021;30(12):1839–1855. PubMed CrossRef
Blakemore SJ, Robbins TW. Decision-making in the adolescent brain. Nat Neurosci. 2012;15(9):1184–1191. PubMed CrossRef
Singh MK, Chang KD, Kelley RG, et al. Reward processing in adolescents with bipolar I disorder. J Am Acad Child Adolesc Psychiatry. 2013;52(1):68–83. PubMed CrossRef
Satterthwaite TD, Kable JW, Vandekar L, et al. Common and dissociable dysfunction of the reward system in bipolar and unipolar depression. Neuropsychopharmacology. 2015;40(9):2258–2268. PubMed CrossRef
Richard-Devantoy S, Gorwood P, Annweiler C, et al. Suicidal behaviours in affective disorders: a deficit of cognitive inhibition? Can J Psychiatry. 2012;57(4):254–262. PubMed CrossRef
Richard-Devantoy S, Olié E, Guillaume S, et al. Decision-making in unipolar or bipolar suicide attempters. J Affect Disord. 2016;190:128–136. PubMed CrossRef
Mann JJ, Arango VA, Avenevoli S, et al. Candidate endophenotypes for genetic studies of suicidal behavior. Biol Psychiatry. 2009;65(7):556–563. PubMed CrossRef
McHugh CM, Chun Lee RS, Hermens DF, et al. Impulsivity in the self-harm and suicidal behavior of young people: a systematic review and meta-analysis. J Psychiatr Res. 2019;116:51–60. PubMed CrossRef
Clark L, Dombrovski AY, Siegle GJ, et al. Impairment in risk-sensitive decision-making in older suicide attempters with depression. Psychol Aging. 2011;26(2):321–330. PubMed CrossRef
Bechara A, Damasio AR, Damasio H, et al. Insensitivity to future consequences following damage to human prefrontal cortex. Cognition. 1994;50(1–3):7–15. PubMed CrossRef
Rogers RD, Everitt BJ, Baldacchino A, et al. Dissociable deficits in the decision-making cognition of chronic amphetamine abusers, opiate abusers, patients with focal damage to prefrontal cortex, and tryptophan-depleted normal volunteers: evidence for monoaminergic mechanisms. Neuropsychopharmacology. 1999;20(4):322–339. PubMed CrossRef
Gorlyn M, Keilp JG, Oquendo MA, et al. Iowa gambling task performance in currently depressed suicide attempters. Psychiatry Res. 2013;207(3):150–157. PubMed CrossRef
Chamberlain SR, Odlaug BL, Schreiber LR, et al. Clinical and neurocognitive markers of suicidality in young adults. J Psychiatr Res. 2013;47(5):586–591. PubMed CrossRef
Dimick MK, Hird MA, Sultan AA, et al. Resting-state functional connectivity indicators of risk and resilience for self-harm in adolescent bipolar disorder. Psychol Med. 2023;53(8):3377–3386. PubMed
Dimick MK, Kennedy KG, Mitchell RHB, et al. Neurostructural differences associated with self-harm in youth bipolar disorder. Bipolar Disord. 2022;24(3):275–285. PubMed
Fan S, Lippard ETC, Sankar A, et al. Gray and white matter differences in adolescents and young adults with prior suicide attempts across bipolar and major depressive disorders. J Affect Disord. 2019;245:1089–1097. PubMed CrossRef
Johnston JAY, Wang F, Liu J, et al. Multimodal neuroimaging of frontolimbic structure and function associated with suicide attempts in adolescents and young adults with bipolar disorder. Am J Psychiatry. 2017;174(7):667–675. PubMed CrossRef
Lippard ETC, Johnston JAY, Spencer L, et al. Preliminary examination of gray and white matter structure and longitudinal structural changes in frontal systems associated with future suicide attempts in adolescents and young adults with mood disorders. J Affect Disord. 2019;245:1139–1148. PubMed CrossRef
Huber RS, Subramaniam P, Kondo DG, et al. Reduced lateral orbitofrontal cortex volume and suicide behavior in youth with bipolar disorder. Bipolar Disord. 2019;21(4):321–329. PubMed CrossRef
Dickstein DP, Treland JE, Snow J, et al. Neuropsychological performance in pediatric bipolar disorder. Biol Psychiatry. 2004;55(1):32–39. PubMed CrossRef
Frías Á, Palma C, Farriols N. Neurocognitive impairments among youth with pediatric bipolar disorder: a systematic review of neuropsychological research. J Affect Disord. 2014;166:297–306. PubMed CrossRef
Kaufman J, Birmaher B, Brent D, et al. Schedule for affective disorders and schizophrenia for school-age children-present and lifetime version (K-SADS-PL): initial reliability and validity data. J Am Acad Child Adolesc Psychiatry. 1997;36(7):980–988. PubMed CrossRef
Axelson D, Birmaher BJ, Brent D, et al. A preliminary study of the Kiddie Schedule for Affective Disorders and Schizophrenia for School-Age Children mania rating scale for children and adolescents. J Child Adolesc Psychopharmacol. 2003;13(4):463–470. PubMed CrossRef
Chambers WJ, Puig-Antich J, Hirsch M, et al. The assessment of affective disorders in children and adolescents by semistructured interview: test-retest reliability of the Schedule for Affective Disorders and Schizophrenia for School-Age Children, Present Episode Version. Arch Gen Psychiatry. 1985;42(7):696–702. PubMed CrossRef
Axelson D, Birmaher B, Strober M, et al. Phenomenology of children and adolescents with bipolar spectrum disorders. Arch Gen Psychiatry. 2006;63(10):1139–1148. PubMed CrossRef
Shaffer D, Gould MS, Brasic J, et al. A Children’s Global Assessment Scale (CGAS). Arch Gen Psychiatry. 1983;40(11):1228–1231. PubMed CrossRef
Weissman MM, Wickramaratne P, Adams P, et al. Brief screening for family psychiatric history: the Family History Screen. Arch Gen Psychiatry. 2000;57(7):675–682. PubMed CrossRef
Petersen AC, Crockett L, Richards M, et al. A self-report measure of pubertal status: reliability, validity, and initial norms. J Youth Adolesc. 1988;17(2):117–133. PubMed CrossRef
Keller MB, Lavori PW, Friedman B, et al. The Longitudinal Interval Follow-up Evaluation: a comprehensive method for assessing outcome in prospective longitudinal studies. Arch Gen Psychiatry. 1987;44(6):540–548. PubMed CrossRef
Wechsler D. WASI-II: Wechsler Abbreviated Scale of Intelligence. PsychCorp; 2011.
Team RCR. A Language and Environment for Statistical Computing. R Foundation for Statistical Computing; 2022.
Benjamini Y, Hochberg Y. Controlling the false discovery rate: a practical and powerful approach to multiple testing. J R Stat Soc B. 1995;57(1):289–300. CrossRef
Alacreu-Crespo A, Olié E, Seneque M, et al. Decision-making skills moderate the relationship between psychological and physical pain with suicidal behavior in depressed patients. Psychother Psychosom. 2019;88(3):190–191. PubMed CrossRef
Bechara A, Damasio H, Damasio AR. Emotion, decision making and the orbitofrontal cortex. Cereb Cortex. 2000;10(3):295–307. PubMed CrossRef
Rimkeviciene J, O’Gorman J, De Leo D. Impulsive suicide attempts: a systematic literature review of definitions, characteristics and risk factors. J Affect Disord. 2015;171:93–104. PubMed CrossRef
Malloy-Diniz LF, Neves FS, Abrantes SS, et al. Suicide behavior and neuropsychological assessment of type I bipolar patients. J Affect Disord. 2009;112(1-3):231–236. PubMed CrossRef
Ponsoni A, Branco LD, Cotrena C, et al. Self-reported inhibition predicts history of suicide attempts in bipolar disorder and major depression. Compr Psychiatry. 2018;82:89–94. PubMed CrossRef
Olié E, Seyller M, Beziat S, et al. Clinical and neuropsychological characteristics of euthymic bipolar patients having a history of severe suicide attempt. Acta Psychiatr Scand. 2015;131(2):129–138. PubMed CrossRef
Cipriani A, Hawton K, Stockton S. Lithium in the prevention of suicide in mood disorders: updated systematic review and meta-analysis. 2013;3646:1–13.
Adida M, Jollant F, Clark L, et al. Lithium might be associated with better decision-making performance in euthymic bipolar patients. Eur Neuropsychopharmacol. 2015;25(6):788–797. PubMed CrossRef
Müller-Oerlinghausen B, Lewitzka U. Lithium reduces pathological aggression and suicidality: a mini-review. Neuropsychobiology. 2010;62(1):43–49. PubMed CrossRef
Hollander E, Pallanti S, Allen A, et al. Does sustained-release lithium reduce impulsive gambling and affective instability versus placebo in pathological gamblers with bipolar spectrum disorders? Am J Psychiatry. 2005;162(1):137–145. PubMed CrossRef
Dell’Osso B, Altamura AC, Allen A, et al. Epidemiologic and clinical updates on impulse control disorders: a critical review. Eur Arch Psychiatry Clin Neurosci. 2006;256(8):464–475. PubMed CrossRef