depression disorder case study examples

Mental Health Case Study: Understanding Depression through a Real-life Example

Through the lens of a gripping real-life case study, we delve into the depths of depression, unraveling its complexities and shedding light on the power of understanding mental health through individual experiences. Mental health case studies serve as invaluable tools in our quest to comprehend the intricate workings of the human mind and the various conditions that can affect it. By examining real-life examples, we gain profound insights into the lived experiences of individuals grappling with mental health challenges, allowing us to develop more effective strategies for diagnosis, treatment, and support.

The Importance of Case Studies in Understanding Mental Health

Case studies play a crucial role in the field of mental health research and practice. They provide a unique window into the personal narratives of individuals facing mental health challenges, offering a level of detail and context that is often missing from broader statistical analyses. By focusing on specific cases, researchers and clinicians can gain a deeper understanding of the complex interplay between biological, psychological, and social factors that contribute to mental health conditions.

One of the primary benefits of using real-life examples in mental health case studies is the ability to humanize the experience of mental illness. These narratives help to break down stigma and misconceptions surrounding mental health conditions, fostering empathy and understanding among both professionals and the general public. By sharing the stories of individuals who have faced and overcome mental health challenges, case studies can also provide hope and inspiration to those currently struggling with similar issues.

Depression, in particular, is a common mental health condition that affects millions of people worldwide. Disability Function Report Example Answers for Depression and Bipolar: A Comprehensive Guide offers valuable insights into how depression can impact daily functioning and the importance of accurate reporting in disability assessments. By examining depression through the lens of a case study, we can gain a more nuanced understanding of its manifestations, challenges, and potential treatment approaches.

Understanding Depression

Before delving into our case study, it’s essential to establish a clear understanding of depression and its impact on individuals and society. Depression is a complex mental health disorder characterized by persistent feelings of sadness, hopelessness, and loss of interest in activities. It can affect a person’s thoughts, emotions, behaviors, and overall well-being.

Some common symptoms of depression include:

– Persistent sad, anxious, or “empty” mood – Feelings of hopelessness or pessimism – Irritability – Loss of interest or pleasure in hobbies and activities – Decreased energy or fatigue – Difficulty concentrating, remembering, or making decisions – Sleep disturbances (insomnia or oversleeping) – Appetite and weight changes – Physical aches or pains without clear physical causes – Thoughts of death or suicide

The prevalence of depression worldwide is staggering. According to the World Health Organization, more than 264 million people of all ages suffer from depression globally. It is a leading cause of disability and contributes significantly to the overall global burden of disease. The impact of depression extends far beyond the individual, affecting families, communities, and economies.

Depression can have profound consequences on an individual’s quality of life, relationships, and ability to function in daily activities. It can lead to decreased productivity at work or school, strained personal relationships, and increased risk of other health problems. The economic burden of depression is also substantial, with costs associated with healthcare, lost productivity, and disability.

The Significance of Case Studies in Mental Health Research

Case studies serve as powerful tools in mental health research, offering unique insights that complement broader statistical analyses and controlled experiments. They allow researchers and clinicians to explore the nuances of individual experiences, providing a rich tapestry of information that can inform our understanding of mental health conditions and guide the development of more effective treatment strategies.

One of the key advantages of case studies is their ability to capture the complexity of mental health conditions. Unlike standardized questionnaires or diagnostic criteria, case studies can reveal the intricate interplay between biological, psychological, and social factors that contribute to an individual’s mental health. This holistic approach is particularly valuable in understanding conditions like depression, which often have multifaceted causes and manifestations.

Case studies also play a crucial role in the development of treatment strategies. By examining the detailed accounts of individuals who have undergone various interventions, researchers and clinicians can identify patterns of effectiveness and potential barriers to treatment. This information can then be used to refine existing approaches or develop new, more targeted interventions.

Moreover, case studies contribute to the advancement of mental health research by generating hypotheses and identifying areas for further investigation. They can highlight unique aspects of a condition or treatment that may not be apparent in larger-scale studies, prompting researchers to explore new avenues of inquiry.

Examining a Real-life Case Study of Depression

To illustrate the power of case studies in understanding depression, let’s examine the story of Sarah, a 32-year-old marketing executive who sought help for persistent feelings of sadness and loss of interest in her once-beloved activities. Sarah’s case provides a compelling example of how depression can manifest in high-functioning individuals and the challenges they face in seeking and receiving appropriate treatment.

Background: Sarah had always been an ambitious and driven individual, excelling in her career and maintaining an active social life. However, over the past year, she began to experience a gradual decline in her mood and energy levels. Initially, she attributed these changes to work stress and the demands of her busy lifestyle. As time went on, Sarah found herself increasingly isolated, withdrawing from friends and family, and struggling to find joy in activities she once loved.

Presentation of Symptoms: When Sarah finally sought help from a mental health professional, she presented with the following symptoms:

– Persistent feelings of sadness and emptiness – Loss of interest in hobbies and social activities – Difficulty concentrating at work – Insomnia and daytime fatigue – Unexplained physical aches and pains – Feelings of worthlessness and guilt – Occasional thoughts of death, though no active suicidal ideation

Initial Diagnosis: Based on Sarah’s symptoms and their duration, her therapist diagnosed her with Major Depressive Disorder (MDD). This diagnosis was supported by the presence of multiple core symptoms of depression that had persisted for more than two weeks and significantly impacted her daily functioning.

The Treatment Journey

Sarah’s case study provides an opportunity to explore the various treatment options available for depression and examine their effectiveness in a real-world context. Supporting a Caseworker’s Client Who Struggles with Depression offers valuable insights into the role of support systems in managing depression, which can complement professional treatment approaches.

Overview of Treatment Options: There are several evidence-based treatments available for depression, including:

1. Psychotherapy: Various forms of talk therapy, such as Cognitive Behavioral Therapy (CBT) and Interpersonal Therapy (IPT), can help individuals identify and change negative thought patterns and behaviors associated with depression.

2. Medication: Antidepressants, such as Selective Serotonin Reuptake Inhibitors (SSRIs), can help regulate brain chemistry and alleviate symptoms of depression.

3. Combination Therapy: Many individuals benefit from a combination of psychotherapy and medication.

4. Lifestyle Changes: Exercise, improved sleep habits, and stress reduction techniques can complement other treatments.

5. Alternative Therapies: Some individuals find relief through approaches like mindfulness meditation, acupuncture, or light therapy.

Treatment Plan for Sarah: After careful consideration of Sarah’s symptoms, preferences, and lifestyle, her treatment team developed a comprehensive plan that included:

1. Weekly Cognitive Behavioral Therapy sessions to address negative thought patterns and develop coping strategies.

2. Prescription of an SSRI antidepressant to help alleviate her symptoms.

3. Recommendations for lifestyle changes, including regular exercise and improved sleep hygiene.

4. Gradual reintroduction of social activities and hobbies to combat isolation.

Effectiveness of the Treatment Approach: Sarah’s response to treatment was monitored closely over the following months. Initially, she experienced some side effects from the medication, including mild nausea and headaches, which subsided after a few weeks. As she continued with therapy and medication, Sarah began to notice gradual improvements in her mood and energy levels.

The CBT sessions proved particularly helpful in challenging Sarah’s negative self-perceptions and developing more balanced thinking patterns. She learned to recognize and reframe her automatic negative thoughts, which had been contributing to her feelings of worthlessness and guilt.

The combination of medication and therapy allowed Sarah to regain the motivation to engage in physical exercise and social activities. As she reintegrated these positive habits into her life, she experienced further improvements in her mood and overall well-being.

The Outcome and Lessons Learned

Sarah’s journey through depression and treatment offers valuable insights into the complexities of mental health and the effectiveness of various interventions. Understanding the Link Between Sapolsky and Depression provides additional context on the biological underpinnings of depression, which can complement the insights gained from individual case studies.

Progress and Challenges: Over the course of six months, Sarah made significant progress in managing her depression. Her mood stabilized, and she regained interest in her work and social life. She reported feeling more energetic and optimistic about the future. However, her journey was not without challenges. Sarah experienced setbacks during particularly stressful periods at work and struggled with the stigma associated with taking medication for mental health.

One of the most significant challenges Sarah faced was learning to prioritize her mental health in a high-pressure work environment. She had to develop new boundaries and communication strategies to manage her workload effectively without compromising her well-being.

Key Lessons Learned: Sarah’s case study highlights several important lessons about depression and its treatment:

1. Early intervention is crucial: Sarah’s initial reluctance to seek help led to a prolongation of her symptoms. Recognizing and addressing mental health concerns early can prevent the condition from worsening.

2. Treatment is often multifaceted: The combination of medication, therapy, and lifestyle changes proved most effective for Sarah, underscoring the importance of a comprehensive treatment approach.

3. Recovery is a process: Sarah’s improvement was gradual and non-linear, with setbacks along the way. This emphasizes the need for patience and persistence in mental health treatment.

4. Social support is vital: Reintegrating social activities and maintaining connections with friends and family played a crucial role in Sarah’s recovery.

5. Workplace mental health awareness is essential: Sarah’s experience highlights the need for greater understanding and support for mental health issues in professional settings.

6. Stigma remains a significant barrier: Despite her progress, Sarah struggled with feelings of shame and fear of judgment related to her depression diagnosis and treatment.

Sarah’s case study provides a vivid illustration of the complexities of depression and the power of comprehensive, individualized treatment approaches. By examining her journey, we gain valuable insights into the lived experience of depression, the challenges of seeking and maintaining treatment, and the potential for recovery.

The significance of case studies in understanding and treating mental health conditions cannot be overstated. They offer a level of detail and nuance that complements broader research methodologies, providing clinicians and researchers with invaluable insights into the diverse manifestations of mental health disorders and the effectiveness of various interventions.

As we continue to explore mental health through case studies, it’s important to recognize the diversity of experiences within conditions like depression. Personal Bipolar Psychosis Stories: Understanding Bipolar Disorder Through Real Experiences offers insights into another complex mental health condition, illustrating the range of experiences individuals may face.

Furthermore, it’s crucial to consider how mental health issues are portrayed in popular culture, as these representations can shape public perceptions. Understanding Mental Disorders in Winnie the Pooh: Exploring the Depiction of Depression provides an interesting perspective on how mental health themes can be embedded in seemingly lighthearted stories.

The field of mental health research and treatment continues to evolve, driven by the insights gained from individual experiences and comprehensive studies. By combining the rich, detailed narratives provided by case studies with broader research methodologies, we can develop more effective, personalized approaches to mental health care. As we move forward, it is essential to continue exploring and sharing these stories, fostering greater understanding, empathy, and support for those facing mental health challenges.

References:

1. World Health Organization. (2021). Depression. Retrieved from https://www.who.int/news-room/fact-sheets/detail/depression

2. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

3. Beck, A. T., & Alford, B. A. (2009). Depression: Causes and treatment. University of Pennsylvania Press.

4. Cuijpers, P., Quero, S., Dowrick, C., & Arroll, B. (2019). Psychological treatment of depression in primary care: Recent developments. Current Psychiatry Reports, 21(12), 129.

5. Malhi, G. S., & Mann, J. J. (2018). Depression. The Lancet, 392(10161), 2299-2312.

6. Otte, C., Gold, S. M., Penninx, B. W., Pariante, C. M., Etkin, A., Fava, M., … & Schatzberg, A. F. (2016). Major depressive disorder. Nature Reviews Disease Primers, 2(1), 1-20.

7. Sapolsky, R. M. (2004). Why zebras don’t get ulcers: The acclaimed guide to stress, stress-related diseases, and coping. Holt paperbacks.

8. Yin, R. K. (2017). Case study research and applications: Design and methods. Sage publications.

Similar Posts

Semaglutide and Depression: Understanding the Connection

As scientists unravel the complex interplay between weight-loss medications and mental health, a surprising connection between Semaglutide and depression has emerged, sparking both concern and curiosity in the medical community. This revelation has prompted researchers and healthcare professionals to delve deeper into the potential implications of this relationship, seeking to understand the mechanisms at play…

Is Depression Selfish? Understanding the Relationship Between Mental Health and Selfishness

Shattering the misconception that depression equates to selfishness, we delve into the intricate relationship between mental health and self-preservation, challenging societal stigmas along the way. Depression is a complex mental health condition that affects millions of people worldwide, yet it remains widely misunderstood and stigmatized. One of the most damaging misconceptions is the idea that…

Understanding Self-Loathing: Is it a Sign of Depression?

Self-loathing is a complex emotional state that can significantly impact an individual’s mental health and overall well-being. It’s a feeling that often goes hand in hand with depression, creating a challenging cycle that can be difficult to break. In this article, we’ll explore the intricate relationship between self-loathing and depression, examining their signs, symptoms, and…

Understanding Reciprocal Changes in ECG: A Comprehensive Guide to Horizontal ST Depression

Electrocardiography (ECG) is a fundamental diagnostic tool in cardiology, providing crucial insights into the heart’s electrical activity. Among the various patterns and changes observed in ECG readings, reciprocal changes play a significant role in identifying and understanding cardiac events. This comprehensive guide delves into the intricacies of reciprocal changes in ECG, with a particular focus…

Understanding Obdurate Depression: Causes, Symptoms, and Treatment Options

Locked in an unyielding grip, obdurate depression challenges millions worldwide, defying conventional treatments and leaving sufferers desperately searching for a glimmer of hope. This persistent and treatment-resistant form of depression can be a formidable adversary, often leaving individuals feeling trapped in a seemingly endless cycle of despair. However, understanding the nature of obdurate depression, its…

Understanding the Link Between COVID-19, Depression, and Anxiety

As the world grappled with an invisible enemy, a silent epidemic of depression and anxiety surged alongside COVID-19, intertwining physical and mental health in unprecedented ways. The global pandemic not only threatened our physical well-being but also took a significant toll on our mental health, creating a complex web of challenges that affected millions of…

Ohio State nav bar

The Ohio State University

• BuckeyeLink
• Find People
• Search Ohio State

Patient Case Presentation

Figure 1.  Blue and silver stethoscope (Pixabay, N.D.)

Ms. S.W. is a 48-year-old white female who presented to an outpatient community mental health agency for evaluation of depressive symptoms. Over the past eight weeks she has experienced sad mood every day, which she describes as a feeling of hopelessness and emptiness. She also noticed other changes about herself, including decreased appetite, insomnia, fatigue, and poor ability to concentrate. The things that used to bring Ms. S.W. joy, such as gardening and listening to podcasts, are no longer bringing her the same happiness they used to. She became especially concerned as within the past two weeks she also started experiencing feelings of worthlessness, the perception that she is a burden to others, and fleeting thoughts of death/suicide.

Ms. S.W. acknowledges that she has numerous stressors in her life. She reports that her daughter’s grades have been steadily declining over the past two semesters and she is unsure if her daughter will be attending college anymore. Her relationship with her son is somewhat strained as she and his father are not on good terms and her son feels Ms. S.W. is at fault for this. She feels her career has been unfulfilling and though she’d like to go back to school, this isn’t possible given the family’s tight finances/the patient raising a family on a single income.

Ms. S.W. has experienced symptoms of depression previously, but she does not think the symptoms have ever been as severe as they are currently. She has taken antidepressants in the past and was generally adherent to them, but she believes that therapy was more helpful than the medications. She denies ever having history of manic or hypomanic episodes. She has been unable to connect to a mental health agency in several years due to lack of time and feeling that she could manage the symptoms on her own. She now feels that this is her last option and is looking for ongoing outpatient mental health treatment.

Past Medical History

• Hypertension, diagnosed at age 41

Past Surgical History

• Wisdom teeth extraction, age 22

Pertinent Family History

• Mother with history of Major Depressive Disorder, treated with antidepressants
• Maternal grandmother with history of Major Depressive Disorder, Generalized Anxiety Disorder
• Brother with history of suicide attempt and subsequent inpatient psychiatric hospitalization,
• Brother with history of Alcohol Use Disorder
• Father died from lung cancer (2012)

Pertinent Social History

• Works full-time as an enrollment specialist for Columbus City Schools since 2006
• Has two children, a daughter age 17 and a son age 14
• Divorced in 2015, currently single
• History of some emotional abuse and neglect from mother during childhood, otherwise denies history of trauma, including physical and sexual abuse
• Smoking 1/2 PPD of cigarettes
• Occasional alcohol use (approximately 1-2 glasses of wine 1-2 times weekly; patient had not had any alcohol consumption for the past year until two weeks ago)

• Clinical Psychotherapy
• Clinical Psychology
• Cognitive Behavioral Therapy

Cognitive Behavior Therapy for Depression: A Case Report

• January 2018

• University of Rajshahi

Abstract and Figures

Discover the world's research

• 25+ million members
• 160+ million publication pages
• 2.3+ billion citations

• INT J COGN THER

• Alankrita Rawat

• Roquia Begum

• J CHILD PSYCHOL PSYC

• Genevieve Garratt

• Gita Murli Sawalani
• J CONSULT CLIN PSYCH

• Robert A. Steer
• Sandra Embling

• Nafiza Ferdowshi
• Gordon E. Barnes
• Harry Prosen
• Joseph Wolpe
• Recruit researchers
• Join for free
• Login Email Tip: Most researchers use their institutional email address as their ResearchGate login Password Forgot password? Keep me logged in Log in or Continue with Google Welcome back! Please log in. Email · Hint Tip: Most researchers use their institutional email address as their ResearchGate login Password Forgot password? Keep me logged in Log in or Continue with Google No account? Sign up

• DOI: 10.4172/2165-7920.1000698
• Corpus ID: 151580646

Case Study of Major Depressive Disorder

• Published 22 January 2016
• journal of Clinical Case Reports

5 Citations

Case study of major depression, treatment of psychosis through fear-stimuli identification therapy (fsit): a case report, case study of genophobia & anxiety, pharmacogenomics‐driven prediction of antidepressant treatment outcomes: a machine‐learning approach with multi‐trial replication.

• Highly Influenced

Catechol O‐Methyltransferase Pharmacogenomics: Challenges and Opportunities

Related papers.

Showing 1 through 3 of 0 Related Papers

Recurrent Major Depressive Disorder of a Young Woman

Information & authors, metrics & citations, view options.

This exercise is designed to test your comprehension of material relevant to this issue of Focus as well as your ability to evaluate, diagnose, and manage clinical problems. Answer the questions below to the best of your ability with the information provided, making your decisions as if the individual were one of your patients. Questions are presented at “consideration points” that follow a section that gives information about the case. One or more choices may be correct for each question; make your choices on the basis of your clinical knowledge and the history provided. Read all of the options for each question before making any selections. You are given points on a graded scale for the best possible answer(s), and points are deducted for answers that would result in a poor outcome or delay your arriving at the right answer. Answers that have little or no impact receive zero points. At the end of the exercise, you will add up your points to obtain a total score.

Case Vignette

Consideration point a., case vignette continues, consideration point b., consideration point c., case vignette concludes, answers: scoring, relative weights, and comments, consideration point a, consideration point b, consideration point c.

Information

Published in.

Export Citations

If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. Simply select your manager software from the list below and click Download. For more information or tips please see 'Downloading to a citation manager' in the Help menu .

To download the citation to this article, select your reference manager software.

There are no citations for this item

View options

Login options.

Already a subscriber? Access your subscription through your login credentials or your institution for full access to this article.

Purchase Options

Purchase this article to access the full text.

PPV Articles - Focus

Not a subscriber?

Subscribe Now / Learn More

PsychiatryOnline subscription options offer access to the DSM-5-TR ® library, books, journals, CME, and patient resources. This all-in-one virtual library provides psychiatrists and mental health professionals with key resources for diagnosis, treatment, research, and professional development.

Need more help? PsychiatryOnline Customer Service may be reached by emailing [email protected] or by calling 800-368-5777 (in the U.S.) or 703-907-7322 (outside the U.S.).

Share article link

Copying failed.

PREVIOUS ARTICLE

Next article, request username.

Can't sign in? Forgot your username? Enter your email address below and we will send you your username

If the address matches an existing account you will receive an email with instructions to retrieve your username

Create a new account

Change password, password changed successfully.

Your password has been changed

Reset password

Can't sign in? Forgot your password?

Enter your email address below and we will send you the reset instructions

If the address matches an existing account you will receive an email with instructions to reset your password.

Your Phone has been verified

As described within the American Psychiatric Association (APA)'s Privacy Policy and Terms of Use , this website utilizes cookies, including for the purpose of offering an optimal online experience and services tailored to your preferences. Please read the entire Privacy Policy and Terms of Use. By closing this message, browsing this website, continuing the navigation, or otherwise continuing to use the APA's websites, you confirm that you understand and accept the terms of the Privacy Policy and Terms of Use, including the utilization of cookies.

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

• Advanced Search
• Journal List
• v.15(3); 2023 Mar
• PMC10097604

A Case Study of Depression in High Achieving Students Associated With Moral Incongruence, Spiritual Distress, and Feelings of Guilt

Bahjat najeeb.

1 Institute of Psychiatry, Rawalpindi Medical University, Rawalpindi, PAK

Muhammad Faisal Amir Malik

Asad t nizami, sadia yasir.

Psychosocial and cultural factors play an important, but often neglected, role in depression in young individuals. In this article, we present two cases of young, educated males with major depressive disorder and prominent themes of guilt and spiritual distress. We explore the relationship between moral incongruence, spiritual distress, and feelings of guilt with major depressive episodes by presenting two cases of depression in young individuals who were high-achieving students. Both cases presented with low mood, psychomotor slowing, and selective mutism. Upon detailed history, spiritual distress and feelings of guilt due to internet pornographic use (IPU) and the resulting self-perceived addiction and moral incongruence were linked to the initiation and progression of major depressive episodes. The severity of the depressive episode was measured using the Hamilton Depression Scale (HAM-D). Themes of guilt and shame were measured using the State of Guilt and Shame Scale (SSGS). High expectations from the family were also a source of stress. Hence, it is important to keep these factors in mind while managing mental health problems in young individuals. Late adolescence and early adulthood are periods of high stress and vulnerabe to mental illness. Psychosocial determinants of depression in this age group generally go unexplored and unaddressed leading to suboptimal treatment, particularly in developing countries. Further research is needed to assess the importance of these factors and to determine ways to mitigate them.

Introduction

More attention needs to be paid to the psychological and societal factors which precipitate, prolong, and cause a relapse of depression in high-achieving young individuals. A young, bright individual has to contend with the pressures of -- often quite strenuous -- moral and financial expectations from the family, moral incongruence, spiritual distress, and feelings of guilt.

Moral incongruence is the distress that develops when a person continues to behave in a manner that is at odds with their beliefs. It may be associated with self-perceptions of addictions, including, for example, to pornographic viewing, social networking, and online gaming [ 1 ]. Perceived addiction to pornographic use rather than use is related to the high incidence of feelings of guilt and shame and predicts religious and spiritual struggle [ 2 - 3 ]. Guilt is a negative emotional and cognitive experience that occurs when a person believes that they have negated a standard of conduct or morals. It is a part of the diagnostic criteria for depression and various rating scales for depressive disorders [ 4 ]. Generalized guilt has a direct relationship with major depressive episodes. Guilt can be a possible target for preventive as well as therapeutic interventions in patients who experience major depressive episodes [ 5 ].

We explored the relationship between moral incongruence, spiritual distress, and feelings of guilt with major depressive episodes in high-achieving students. Both patients presented with symptoms of low mood, extreme psychomotor slowing, decreased oral intake, decreased sleep, and mutism. The medical evaluation and lab results were unremarkable. The severity of depressive episodes was measured using the Hamilton Depression Scale (HAM-D). Themes of guilt and shame were measured by using the State of Guilt and Shame Scale (SSGS). This case study was presented as a poster abstract at the ‘RCPsych Faculty of General Adult Psychiatry Annual Conference 2021.’

Case presentation

A 25-year-old Sunni Muslim, Punjabi male educated till Bachelors presented with a one-month history of fearfulness, weeping spells during prolonged prostration, social withdrawal, complaints of progressively decreasing verbal communication to the extent of giving nods and one-word answers, and decreased oral intake. His family believed that the patient's symptoms were the result of ‘Djinn’ possession. This was the patient’s second episode. The first episode was a year ago with similar symptoms of lesser severity that resolved on its own. Before being brought to us, he had been taken to multiple faith healers. No history of substance use was reported. Psychosexual history could not be explored at the time of admission. His pre-morbid personality was significant for anxious and avoidant traits. 

On mental state examination (MSE), the patient had psychomotor retardation. He responded non-verbally, and that too slowly. Once, he wept excessively and said that he feels guilt over some grave sin. He refused to explain further, saying only that ‘I am afraid of myself.’ All baseline investigations returned normal. His score on the Hamilton Depression Rating Scale (HAM-D) was 28 (Very Severe). A diagnosis of major depressive disorder was made. The patient was started on tab sertraline 50 mg per day and tab olanzapine 5 mg per day. After the second electroconvulsive therapy (ECT), his psychomotor retardation improved and he began to open up about his stressors. His HAM-D score at this time was 17 (moderate). He revealed distress due to feelings of excessive guilt and shame due to moral incongruence secondary to internet pornography use (IPU). The frequency and duration of IPU increased during the last six months preceding current illness. That, according to him, led him to withdraw socially and be fearful. He felt the burden of the high financial and moral expectations of the family. He complained that his parents were overbearing and overinvolved in his life. His family lacked insight into the cause of his illness and had difficulty accepting his current state. All these factors, particularly spiritual distress, were important in precipitating his illness. He scored high on both the shame and guilt domains (14/25, and 20/25, respectively) of the State of Shame and Guilt Scale (SSGS).

He was discharged after three weeks following a cycle of four ECTs, psychotherapy, and psychoeducation of the patient and family. At the time of discharge, his HAM-D score was 10 (mild) and he reported no distress due to guilt or feeling of shame. He has been doing well for the past 5 months on outpatient follow-up.

A 21-year-old Sunni Muslim, Punjabi male, high-achieving student of high school presented with low mood, low energy, anhedonia, weeping spells, decreased oral intake, decreased talk, and impaired biological functions. His illness was insidious in onset and progressively worsened over the last 4 months. This was his first episode. He was brought to a psychiatric facility after being taken to multiple faith healers. Positive findings on the MSE included psychomotor slowing, and while he followed commands, he remained mute throughout the interview. Neurological examination and laboratory findings were normal. His score on HAM-D was 24 (very severe). He was diagnosed with major depressive disorder and started on tab lorazepam 1 mg twice daily with tab mirtazapine 15 mg which was built up to 30 mg once daily. He steadily improved, and two weeks later his score on HAM-D was 17 (moderate). His scores on SSGS signified excessive shame and guilt (16/25, and 21/25; respectively). He communicated his stressors which pertained to the psychosexual domain: he started masturbating at the age of 15, and he felt guilt following that but continued to do so putting him in a state of moral incongruence. He perceived his IPU as ‘an addiction’ and considered it a ‘gunahe kabira’ (major sin) and reported increased IPU in the months leading to the current depressive episode leading to him feeling guilt and anguish. Initially, during his illness, he was taken to multiple faith healers as the family struggled to recognize the true nature of the disease. Their understanding of the illness was of him being under the influence of ‘Kala Jadu’ (black magic). His parents had high expectations of him due to him being their only male child. After 3 weeks of treatment and psychotherapy, his condition improved and his HAM-D score came out to be 08 (mild). He was discharged on 30 mg mirtazapine HS and seen on fortnightly visits. His guilt and shame resolved with time after the resolution of depressive symptoms and counseling. We lost the follow-up after 6 months.

Late adolescence and young adulthood can be considered a unique and distinct period in the development of an individual [ 6 ]. It is a period of transition marked by new opportunities for development, growth, and evolution, as well as bringing new freedom and responsibilities. At the same time, this period brings interpersonal conflicts and an increased vulnerability to mental health disorders such as depression and suicidality. Biological, social, and psychological factors should all be explored in the etiology of mental health problems presenting at this age [ 6 ].

Socio-cultural factors played a significant role in the development and course of disease in our patients, and these included the authoritarian parenting style, initial lack of awareness about psychiatric illnesses causing a delay in seeking treatment, high expressed emotions in the family, and the burden of expectations from the family and the peer group. The strict and often quite unreasonable societal and family expectations in terms of what to achieve and how to behave and the resultant onus on a high-scoring, bright young individual make for a highly stressful mental state. 

We used the ICD-10 criteria to diagnose depression clinically in our patients and the HAMD-17 to measure the severity of symptoms [ 7 ]. Both our patients had scores signifying severe depression initially. Psychomotor retardation was a prominent and shared clinical feature. Psychomotor retardation is the slowing of cognitive and motor functioning, as seen in slowed speech, thought processes, and motor movements [ 8 - 9 ]. The prevalence of psychomotor retardation in major depressive disorder ranges from 60% to 70% [ 10 ]. While psychomotor retardation often responds poorly to selective serotonin reuptake inhibitors (SSRI), both tricyclic antidepressants (TCAs) and noradrenergic and specific serotonergic antidepressants (NaSSA) produce a better response [ 9 , 11 ]. In addition, ECT shows a high treatment response in cases with significant psychomotor retardation [ 11 - 12 ].

A growing body of evidence shows that shame and guilt are features of numerous mental health problems. Guilt is the negative emotional and cognitive experience that follows the perception of negating or repudiating a set of deeply held morals [ 4 ]. Guilt can be generalized as well as contextual and is distinct from shame [ 13 ]. The distinction between guilt and shame allows for an independent assessment of the association of both guilt and shame with depressive disorder. As an example, a meta-analysis of 108 studies including 22,411 individuals measuring the association of shame and guilt in patients with depressive disorder found both shame and guilt to have a positive association with depressive symptoms. This association was stronger for shame (r=0.43) than for guilt (r=0.28) [ 14 ]. In our study, we used the State of Shame and Guilt Scale (SSGS), to measure the feelings of guilt and shame [ 15 ]. The SSGS is a self-reported measure and consists of 5 items each for subsets of guilt and shame. SSGS scores showed high levels of guilt and shame in both of our patients.

During the course of treatment, we paid special attention to the psychological, cultural, and social factors that likely contributed to the genesis of the illness, delayed presentation to seek professional help, and could explain the recurrence of the depressive episodes. In particular, we observe the importance, particularly in this age group, of family and societal pressure, spiritual distress, moral incongruence, and feelings of guilt and shame. Moral incongruence is when a person feels that his behavior and his values or judgments about that behavior are not aligned. It can cause a person to more negatively perceive a behavior. As an example, the presence of moral congruence in an individual is a stronger contributor to perceiving internet pornographic use (IPU) as addictive than the actual use itself [ 16 ]. Therefore, moral congruence has a significant association with increased distress about IPU, enhanced psychological distress in general, and a greater incidence of perceived addiction to IPU [ 16 ].

Self-perceived addiction is an individual’s self-judgment that he or she belongs to the group of addicts. The pornography problems due to moral incongruence (PPMI) model is one framework that predicts the factors linking problematic pornographic use with self-perceived addiction. This model associates moral incongruence with self-perceived addiction to problematic pornographic use [ 17 ]. A recent study on the US adult population also showed a high association of guilt and shame with moral incongruence regarding IPU [ 18 ]. Another factor of importance in our patients was spiritual distress, which is the internal strain, tension, and conflict with what people hold sacred [ 19 ]. Spiritual distress can be intrapersonal, interpersonal, or supernatural [ 20 ]. Research indicates that IPU causes people to develop spiritual distress that can ultimately lead to depression [ 16 - 17 ].

Conclusions

In both our cases the initial presentation was that of psychomotor slowing, selective mutism, and affective symptoms of low mood, therefore, a diagnosis of depressive illness was made. One week into treatment, improvement was noted both clinically as well as on the psychometric scales. Upon engaging the patients to give an elaborate psychosexual history, moral incongruence, spiritual distress, and feelings of guilt, linked particularly to self-perceived addiction to IPU were found. Sensitivity to the expectations of the parents, the cognizance of failing them because of illness, and their own and family’s lack of understanding of the situation were additional sources of stress. Hence, it is imperative to note how these factors play an important role in the initiation, progression, and relapse of mental health problems in young individuals. 

Acknowledgments

We are thankful to the participants of this study for their cooperation.

The authors have declared that no competing interests exist.

Human Ethics

Consent was obtained or waived by all participants in this study

• Fundamentals of Bipolar Disorder

Fundamentals of Major Depressive Disorder

• Fundamentals of Schizophrenia
• Fundamentals Certificate Program
• Clinical Article Summaries
• Events Calendar
• Interactive Case Study
• Psychopharmacology
• Test Your Knowledge
• Psychiatric Scale NPsychlopedia
• Psychotherapy NPsychlopedia
• Caregiver Resources
• Educate Your Patient
• Quick Guides
• Clinical Insights
• NP Spotlight
• Peer Exchanges

Top results

Patient case navigator: major depressive disorder.

Introduction

Learning Objectives

• How to perform a structured psychiatric interview
• Standardized psychiatric rating scales appropriate for patients with depressive symptoms
• Common barriers to adequate treatment response
• How to assess and monitor patients for treatment side effects and adequate treatment response

Watch the video:

History and Examination

Medical History

Examination

History of Present Illness

Eric is a 60-year-old man who presents to his primary care nurse practitioner, Tina, with irritability, excessive sleeping, and a lack of interest in his usual hobbies, such as attending baseball games and going to the movies with his wife. He also has been spending much time at home alone, watching television, rather than spending time with his friends or wife, as he usually does. Eric recently retired from his job as a general contractor remodeling people’s kitchens and bathrooms. He enjoyed his job very much and felt a sense of pride in helping people make their homes more functional and attractive. However, his job was very physical, and at times stressful, so Eric felt it was time to retire and find something new with which to occupy his time.

Eric was diagnosed with hypothyroidism 5 years ago and has been on medication ever since. Annual lab tests indicate his thyroid levels have remained within the normal range for the past few years. He also has mild hypertension, which is well-controlled at an adequate dose.

Psychosocial History

Eric reports that he has several close friends and that he got along well with people at work. He denies a history of substance misuse and reports that he occasionally drinks a glass of wine with dinner. He does not smoke. Eric describes his marriage as “very good.” He is also close with his adult daughter and enjoys spending time with his 2 grandchildren.

At age 33, Eric experienced a period of depressed mood after losing his job. During that time, he had problems getting out of bed in the morning because he felt hopeless and sad, stopped socializing with friends, and lost about 4 lbs of body weight in 4 weeks without intentionally dieting. He sought treatment from his primary care physician, who referred him to a psychiatrist for medication and a psychologist for outpatient cognitive-behavioral therapy (CBT). Eric worked with his psychiatrist and tried 4 different selective serotonin reuptake inhibitors (SSRIs) before he ultimately found one that seemed to work for him. He and his psychiatrist decided together that he could stop taking the medication after 1 year because his mood had improved and stabilized. He saw his therapist once weekly for approximately 2.5 years and reports that CBT also helped improve his mood and functioning.

Family History

Eric reports that, throughout his life, his mother had “very low periods” when she seemed extremely sad and had trouble functioning. However, she never sought treatment for these episodes.

Eric’s physical examination indicates he is generally healthy for his age. His vital signs are all within the normal range, and the mental status examination indicates he is fully oriented and alert. Eric’s appearance is that of an older man. His affect is flat, and he has trouble making eye contact, often staring at the floor instead.

Patient Interview

Quiz #1: initial presentation and diagnosis, dsm-5 diagnostic criteria for mdd.

MDE Diagnostic Criteria

Safety Plan

Major Depressive Episode (MDE)

A. Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous function; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.

• Depressed mood most of the day, nearly every day, as indicated by either subjective report or observation made by others
• Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day
• Significant weight loss when not dieting or weight gain, or decrease or increase in appetite nearly every day
• Insomnia or hypersomnia nearly every day
• Psychomotor agitation or retardation nearly every day
• Fatigue or loss of energy nearly every day
• Feelings of worthlessness or excessive or inappropriate guilt nearly every day
• Diminished ability to think or concentrate, or indecisiveness, nearly every day
• Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide

B. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of function

C. The episode is not attributable to the physiological effects of a substance or another medical condition

Diagnostic and Statistical Manual of Mental Disorders. 5th ed. American Psychiatric Association; 2013.

• It is important to thoroughly review each of these 9 symptoms with your patients when assessing them for MDD.
• Clinical rating scales can help identify which patients require more in-depth screening for depression.

Quiz #2: DSM-5 Diagnostic Criteria for MDD

Scales for mdd.

PHQ-9 Scale Scoring

QIDS Scale Scoring

Patient Health Questionnaire-9 (PHQ-9)

This scale was developed by Drs Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke, and colleagues with an educational grant from Pfizer inc. No permission required.

Scoring Criteria

Kroenke K, Spitzer RL. Psychiatric Annals. 2002;32:509-521.

The Quick Inventory of Depressive Symptomatology (QIDS)

• The QIDS is a 16-item, multiple-choice questionnaire in which depressive symptoms are rated on a 0-3 scale according to severity
• Items are derived from the 9 diagnostic criteria for major depressive disorder used in the Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV), including sadness, loss of interest or pleasure, poor concentration or decision-making, self-outlook, suicidal ideation, lack of energy, sleep disturbance, appetite change, and psychomotor agitation
• Although the QIDS was initially developed based on DSM-IV criteria, the scale is also compatible with the DSM-5. The core criteria for MDD are consistent across these editions

Rush AJ, et al. Biol Psychiatry. 2003;54(5):573-583.

Bernstein IH, et al. Int J Methods Psychiatr Res. 2009;18(2):138-146.

Quiz #3: Scales for MDD

Treatment initiation and monitoring.

APA Guidelines

Eric's PHQ-9 Score

Treatment Options

American Psychiatric Association (APA) Guidelines for Treatment of MDD

1-2 weeks: Improvement from pharmacologic therapy can be seen as early as 1-2 weeks after starting treatment

2-4 weeks: Some patients may achieve improvement in 2-4 weeks

4-6 weeks: Short-term efficacy trials show antidepressant therapy appears to require 4-6 weeks to achieve maximum therapeutic effects

4-8 weeks: The APA recommends 4-8 weeks of adequate* treatment is needed before concluding that a patient is partially responsive or unresponsive to treatment *Adequate dose and duration Practice Guideline for the Treatment of Patients With Major Depressive Disorder. 3rd ed. American Psychiatric Association; 2010.

*Adequate dose and duration

Practice Guideline for the Treatment of Patients with Major Depressive Disorder. 3rd ed. American Psychiatric Association; 2010.

Quiz #4: Treatment Initiation and Monitoring

Assessing for treatment challenges.

Treatment Challenges

Eric's Updated PHQ-9 Score

Possible Challenges to Antidepressant Therapy

• Suboptimal efficacy due to the wrong dose, inadequate length of time on the medication, or the person's individual biology not being responsive to the medication
• Unpleasant side effects of antidepressants can occur, such as weight gain, insomnia, and sexual dysfunction
• Nonadherence to the antidepressant
• As a reminder, the American Psychiatric Association (APA) recommends 4-8 weeks of adequate* treatment is needed before concluding that a patient is partially responsive or unresponsive to treatment

Practice Guideline for the Treatment of Patients With Major Depressive Disorder. 3rd ed. American Psychiatric Association; 2010.

MDD Diagnosis

Clinical Probes

Treatment Assessment

Monitoring Considerations

Factors to Consider When Making a MDD Diagnosis

• Take a thorough patient history
• Previous or current depressive episodes
• Previous or current manic or hypomanic episodes
• Family history of MDD, bipolar disorder
• Medical comorbidities
• Consider a broad differential diagnosis

Clinical Queries That Aid in Diagnosing Major Depressive Episodes

1. Diagnostic and Statistical Manual of Mental Disorders, 5th Edition. American Psychiatric Association; 2013. 2. Kroenke K, et al. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16(9):606-613.

APA Practice Guidelines on Treatment Assessment

• Wait 4 to 8 weeks to assess treatment response to antidepressants
• In patients without adequate response, clinicians can consider changing or augmenting with a second medication
• Changes to treatment plans, such as augmenting with a second-generation antipsychotic medication, are reasonable if a patient does not have adequate improvement in 6 weeks
• Consistently follow-up with patients to assess treatment effects, adverse medication effects, and risk of self-harm

APA Practice Guidelines note that the frequency of monitoring should be based on:

• Symptom severity (including suicidal ideation)
• Co-occurring disorders (including general medical conditions)
• Treatment adherence
• Availability of social supports
• Frequency and severity of side effects with medication

Tina Matthews-Hayes is a paid consultant for Abbvie Medical Affairs and was compensated for her time.

American Psychiatric Association. Practice Guideline for the Treatment of Patients with Major Depressive Disorder. 3rd ed. American Psychiatric Association; 2010.​

• American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders . 5th ed. American Psychiatric Association; 2013. ​
• Kapfhammer HP. Somatic symptoms in depression. Dialogues Clin Neurosci . 2006;8(2):227-239.​
• Bobo WV. The diagnosis and management of bipolar I and II disorders: clinical practice update. Mayo Clin Proc . 2017;92(10):1532-1551.​
• Kroenke K, Spitzer RL, Williams JBW. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med . 2001;16:606-613.​
• Smarr KL, Keefer AL. Measures of depression and depressive symptoms. Arthritis Care Res . 2011;63(S11):S454-S466. doi:10.1002/acr.20556​
• Rush AJ, Trivedi MH, Ibrahim HM, et al. The 16-Item Quick Inventory of Depressive Symptomatology (QIDS), Clinician Rating (QIDS-C), and Self-Report (QIDS-SR): a psychometric evaluation in patients with chronic major depression. Biol Psychiatry. 2003;54:573-583.​
• Brown ES, Murray M, Carmody TJ, et al. The Quick Inventory of Depressive Symptomatology–Self-report: a psychometric evaluation in patients with asthma and major depressive disorder. Ann Allergy Asthma Immunol. 2008;100(5):433-438. doi:10.1016/S1081-1206(10)60467-X​
• Liu R, Wang F, Liu S, et al. Reliability and validity of the Quick Inventory of Depressive Symptomatology-Self-Report Scale in older adults with depressive symptoms. Front Psychiatry . 2021;12:686711. doi:10.3389/fpsyt.2021.686711 ​
• Bernstein IH, Rush AJ, Suppes T, et al. A psychometric evaluation of the clinician-rated Quick Inventory of Depressive Symptomatology (QIDS-C16) in patients with bipolar disorder. Int J Methods Psychiatr Res . 2009;18(2):138-146. doi:10.1002/mpr.2855​
• Bernstein IH, Rush AJ, Trivedi MH, et al. Psychometric properties of the Quick Inventory of Depressive Symptomatology in adolescents. Int J Methods Psychiatr Res. 2010;19(4):185-194. doi:10.1002/mpr.321 ​
• Kroenke K. Enhancing the clinical utility of depression screening. CMAJ . 2012;184(3):281-282.doi:10.1503/cmaj.112004 ​
• Levinstein MR, Samuels BA. Mechanisms underlying the antidepressant response and treatment resistance. Front Behav Neurosci . 2014;8:208. doi:10.3389/fnbeh.2014.00208​
• Haddad PM, Talbot PS, Anderson IM, McAllister-Williams RH. Managing inadequate antidepressant response in depressive illness. Br Med Bull. 2015;115(1):183-201. doi:10.1093/bmb/ldv03​

This resource is intended for educational purposes only and is intended for US healthcare professionals. Healthcare professionals should use independent medical judgment. All decisions regarding patient care must be handled by a healthcare professional and be made based on the unique needs of each patient.

This is not a diagnostic tool and is not intended to replace a clinical evaluation by a healthcare provider.

Reach out to your family or friends for help if you have thoughts of harming yourself or others, or call the National Suicide Prevention Helpline for information at 800-273-8255.

ABBV-US-00976-MC, V1.0 Approved 12/2023 AbbVie Medical Affairs

Recommended on NP Psych Navigator

Disease Primer

Major depressive disorder (MDD) is one of the most recognized mental disorders in the United States. Learn more about the prevalence, pathophysiology, diagnosis, and management of MDD here.

Clinical Article

State-Dependent Differences in Emotion Regulation Between Unmedicated Bipolar Disorder and Major Depressive Disorder

Rive et al use functional MRI to look at some of the differences between patients with bipolar depression and major depressive disorder.

Unrecognized Bipolar Disorder in Patients With Depression Managed in Primary Care: A Systematic Review and Meta-Analysis

Daveney et al explore the characteristics of patients with mixed symptoms, as compared to those without mixed symptoms, in both bipolar disorder and major depressive disorder.

Welcome To NP Psych Navigator

This website is intended for healthcare professionals inside the United States. Please confirm that you are a healthcare professional inside the US.

You are now leaving NP Psych Navigator

Links to sites outside of NP Psych Navigator are provided as a resource to the viewer. AbbVie Inc accepts no responsibility for the content of non-AbbVie linked sites.

Redirect to:

Academic Support for Nursing Students

No notifications.

Disclaimer: This case study has been written by a student and not our expert nursing writers. View professional sample case studys here.

View full disclaimer

Any opinions, findings, conclusions, or recommendations expressed in this case study are those of the author and do not necessarily reflect the views of NursingAnswers.net. This case study should not be treated as an authoritative source of information when forming medical opinions as information may be inaccurate or out-of-date.

Case Study and Treatment Plan: Major Depressive Disorder and Alcohol Use

Info: 4892 words (20 pages) Nursing Case Study Published: 5th May 2020

Reference this

Tagged: mental health depression alcohol misuse

If you need assistance with writing your nursing case study, our professional nursing case study writing service is here to help!

• Medical supervision for Alcohol Withdrawal (inpatient admission for detoxification)
• Residential rehabilitation
• Pharmacotherapy for post detoxification support and in an attempt to prevent relapse
• AOD counselling weekly for support
• AA Meetings weekly for peer support in relapse prevention
• Personal counselling
• Psychology sessions (ie Cognitive Behavioural Therapy (CBT))
• Taking medication as prescribed
• Attending weekly AOD counselling sessions
• Attending weekly AA meetings
• Attending regular counselling
• Attending psychology (CBT) sessions
• Able to indicate some positivity and hope for his future
• Regular attendance at gardens with support worker
• Regular conversations with family members and support people

Our nursing and healthcare experts are ready and waiting to assist with any writing project you may have, from simple essay plans, through to full nursing dissertations.

• Adams, P. J.(2007) Fragmented Intimacy: Addiction in a social world. Springer Science &Business Media
• American Psychiatric Association (1987). Diagnostic and Statistical Manual of Mental Disorders (3 rd ed.,rev.) Washington, DC
• American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington,VA, American Psychiatric Association (2013).
• Baker, A., & Velleman, R. (Eds.). (2007). Clinical handbook of co-existing mental health and drug and alcohol problems . Routledge.
• Brown, R. A., Evans, D. M., Miller, I. W., Burgess, E. S., & Mueller, T. I. (1997). Cognitive–behavioral treatment for depression in alcoholism. Journal of consulting and clinical psychology , 65 (5), 715.
• Brown, R. A., & Ramsey, S. E. (2000). Addressing comorbid depressive symptomatology in alcohol treatment. Professional Psychology: Research and Practice , 31 (4), 418.
• Durie, M. (1998). Whaiora: Maori health development. Oxford University Press
• Regier, D.A., Farmer, M.E., Rae, D.S., Locke, B. Z., Keith, S.J., Judd, L. L., & Goodwin, F.K.(1990) Comorbidity of Mental disorders with alcohol and other drug abuse: Results from the Epidemiologic Catchment Area (ECA) Study. Journal of the American Medical Association, 264,2511-2518
• Turner, R., & Wehl, C. (1984). Treatment of unipolar depression in problem drinkers.   Advances in behavioural research and Therapy, 6, 115-125

Cite This Work

To export a reference to this article please select a referencing stye below:

Related Services

• Case Study Service

• Nursing Essay Writing Service

• Reflective Writing Service

Related Content

Content relating to: "alcohol misuse"

Alcohol misuse as defined by the World Health Organization (WHO) is the alcohol use that places people at risk for problems, including “at-risk use,” “clinical alcohol abuse,” and “dependence.” Although the use of alcohol brings with it a number of pleasures, alcohol increases the risk of a wide range of social harms, generally in a dose dependent manner.

Related Articles

Patient-Nurse Relationship: Alcohol Dependency Care

Diagnosis J.H was admitted to Unit 9 with a diagnosis of alcohol dependence causing induced mood disorder with depressive features. The diagnostic criteria outlined by the DSM-IV for substance depende...

Alcohol Withdrawal Protocol for Hospitals

Social and Personal Effects of Alcoholism Alcohol is the term we use for ethanol, the substance suitable for people to drink. Another type of alcohol is methanol and it is harmful to people. Alcohol ...

The Epidemiology of Alcohol Abuse and Alcoholism

Introduction According to Alcohol Concern Organisation (2015) more than 9 million people in England consume alcoholic beverages more than the recommended daily limits. In relation to this, the Nationa...

DMCA / Removal Request

If you are the original writer of this case study and no longer wish to have your work published on the NursingAnswers.net website then please:

Our academic writing and marking services can help you!

• Marking Service
• Samples of our Work
• Full Service Portfolio

Related Lectures

Study for free with our range of nursing lectures!

• Drug Classification
• Emergency Care
• Health Observation
• Palliative Care
• Professional Values

Write for Us

Do you have a 2:1 degree or higher in nursing or healthcare?

Study Resources

Free resources to assist you with your nursing studies!

• APA Citation Tool
• Example Nursing Essays
• Example Nursing Assignments
• Example Nursing Case Studies
• Reflective Nursing Essays
• Nursing Literature Reviews
• Free Resources
• Reflective Model Guides
• Nursing and Healthcare Pay 2021

• Find Your Calm: Managing Stress & Anxiety

Stress Symptoms

What Is Stress?

Stress is your body's response to a challenging or demanding situation. When you feel stressed, your body releases certain hormones. Your hormones are chemical signals your body uses to tell your body systems what to do. The hormones your body releases when you're stressed get you ready to meet the challenge or demand in your environment. During the stress response, your body gets ready to flee or fight by increasing your heart rate, breathing rate, and blood pressure.

Not all stress is bad. In small doses, stress can help you accomplish tasks or prevent you from getting hurt. For example, stress is what makes you slam on the brakes to avoid hitting a suddenly stopped car in front of you. That's a good thing.

But people handle stressful situations differently. What stresses you out may be of little concern to someone else. 

Stress can be a short-term response to something that happens once or only a few times or a long-term response to something that keeps happening. Our bodies can usually handle short-term stress without long-term effects. But long-term or chronic stress can make you sick, both mentally and physically.

The first step to managing your stress is to know the symptoms. But recognizing stress symptoms may be harder than you think. Many of us are so used to feeling stressed that we may not know it until we get sick. Read on to learn more about the various symptoms you may have when you're stressed.

Difference between stress and distress

Stress is a normal reaction to challenges in your physical environment or in your perceptions of what's happening around you. Experts consider distress to be stress that is severe, prolonged, or both. Distress is when you feel you’re under more stress than you can handle.

Emotional Stress Symptoms

Mental symptoms of emotional stress include:

• Feeling more emotional than usual, especially feeling grumpy, teary, or angry
• Feeling anxious, overwhelmed, nervous, or on edge
• Feeling sad or depressed
• Feeling restless
• Trouble keeping track of or remembering things
• Trouble getting your work done, solving problems, making decisions, or concentrating 

Physical Stress Symptoms

Symptoms of stress that you might feel in your body include:

• Clenching your jaw and grinding your teeth
• Shoulder, neck, or back pain; general body aches, pains, and tense muscles
• Chest pain, increased heart rate, heaviness in your chest
• Shortness of breath
• Feeling more tired than usual (fatigue)
• Sleeping more or less than usual
• Upset stomach , including diarrhea , constipation , and nausea
• Loss of sexual desire and/or ability
• Getting sick more easily, such as getting colds and infections often

Respiratory distress

This is when you aren't getting enough oxygen or are having to work really hard to breathe. If you or a loved one has symptoms of respiratory distress, you need to call 911 and get to the ER as soon as possible. Signs include:

• Breathing faster than usual
• Color changes of your skin, mouth, lips, or fingernails. A blue color around your mouth, lips, or fingernails usually shows you aren't getting enough oxygen. Your skin may also look pale or gray.
• Grunting when you breath out
• A whistling with each breath (wheezing)
• Nose flaring
• Chest sinking below your neck or under your breastbone with each breath (retractions)
• Increased sweating, especially cold, clammy skin on your forehead
• Leaning forward while sitting to help take deeper breaths

Cognitive Stress Symptoms

Symptoms of stress that affect your mental performance include:

• Trouble getting your work done, solving problems, making decisions, or concentrating
• Feeling less commitment to your work
• Lack of motivation
• Negative thinking

Behavioral Stress Symptoms

Symptoms of behavioral stress include:

• Changes in your eating habits; losing or gaining weight
• Procrastinating and avoiding responsibilities
• Using alcohol, tobacco, or drugs to feel better
• Avoiding your friends and family; isolating yourself from others
• Failing to meet your deadlines
• Increased absences at school or work
• Doing your work more slowly
• Exercising less often

Symptoms of Chronic Stress

Chronic stress is when you experience stress over an extended time. This can have negative effects on your body and your mental state, and it can increase your risk of cardiovascular disease, anxiety, and depression.

In general, the symptoms of chronic stress are the same as those for shorter-term stress. You may not have all these symptoms, but if you have more than three symptoms and they last for a few weeks, you may have chronic stress. Potential symptoms to look for include:

• Aches and pains
• Changes in your sleeping patterns, such as insomnia or sleepiness
• Changes in your social behavior, such as avoiding other people
• Changes in your emotional response to others
• Emotional withdrawal
• Low energy, fatigue
• Unfocused or cloudy thinking
• Changes in your appetite
• Increased alcohol or drug use
• Getting sick more often than usual

Is It Stress or Something Else?

You may be dealing with something more serious than day-to-day stress if you have symptoms over a period of time even though you've tried to cope using healthy mechanisms. Long-term stress is linked to number of mental health disorders, such as:

• Chronic stress
• Substance use disorder
• Disordered eating

It may be time to visit your doctor if you're struggling to cope with the stress in your life or you have mental health problems from long-term stress. They can help you figure out ways of coping in a healthy way or refer you to a mental health professional who can help you.

Posttraumatic Stress Disorder

Posttraumatic stress disorder (PTSD) is mental health condition that you may have after you have or witness a traumatic event, such as a natural disaster, accident, or violence. PTSD overwhelms your ability to cope with new stress. PTSD can lead to symptoms such as intrusive memories, avoidance behaviors, and hyperarousal. 

These symptoms can cause significant problems in your work or relationships. T alk to your doctor or a mental health professional if you've had or witnessed a traumatic event and have disturbing thoughts and feelings about it for more than a month, if your thoughts and feelings are severe, or if you feel like you're having trouble getting your life back on track.

What Are the Consequences of Long-Term Stress?

Ongoing, chronic stress can trigger or worsen many serious health problems, including:

• Mental health problems, such as depression, anxiety, and personality disorders
• Cardiovascular disease, including heart disease , high blood pressure, abnormal heart rhythms, heart attacks, and strokes
• Obesity and other eating disorders
• Menstrual problems
• Sexual dysfunction, such as impotence and premature ejaculation in men and loss of sexual desire in men and women
• Skin and hair problems , such as acne, psoriasis, and eczema, and permanent hair loss
• Gastrointestinal problems, such as GERD, gastritis , ulcerative colitis, and irritable bowel syndrome

Help Is Available for Stress

Stress is a part of life. What matters most is how you handle it. The best thing you can do to prevent stress overload and the health consequences that come with it is to know your stress symptoms.

If you or a loved one is feeling overwhelmed by stress, talk to your doctor. Many symptoms of stress can also be signs of other health problems. Your doctor can evaluate your symptoms and rule out other conditions. If stress is to blame, your doctor can recommend a therapist or counselor to help you better handle your stress.

Stress Takeaways

Stress is your body's response to a challenging or demanding situation. It can affect you physically, mentally, and behaviorally, especially when you have chronic stress. Chronic stress is when you are stressed for an extended time. Chronic stress can make it more likely for you to develop other mental health disorders, such as anxiety or depression. It can also affect your heart health and digestive health. If you're stressed and having trouble coping, it may be time for you to see your doctor or a mental health professional.

Stress FAQs

What can extreme stress cause?

Extreme stress, especially if it's prolonged, can cause emotional distress. And stress from a traumatic event, which is usually extreme, can cause posttraumatic stress disorder (PTSD). These are more serious cases of stress that overwhelm your ability to manage on your own. You may need to get a professional's help to get back on track. If you feel like you're having trouble managing your emotions, talk to your doctor. They can help you or direct you to someone who can help you.

Can stress make you throw up?

Yes, stress can make you throw up. Your digestive system is one of the many systems that stress can affect. In fact, you may have a whole range of other digestive symptoms, such as nausea, pain, and constipation or diarrhea. Not everyone has stress nausea or vomiting, but you may be more prone to it if you have a gastrointestinal condition, such as irritable bowel syndrome (IBS), or you have anxiety or depression.

You may be able to tell if you're stress vomiting if your episode passes when the stress goes away. If it doesn't, then your episode may be caused by something else. It's time to get checked out by your doctor if you have more than a couple of episodes or you can't figure out what's causing them.

Show Sources

Chu, B. Physiology, Stress Reaction , StatPearls Publishing, 2024.

American Psychological Association: "Stress effects on the body."

MedlinePlus: "Stress."

Mayo Clinic: "Stress management," "Emotional exhaustion: When your feelings feel overwhelming," "Post-traumatic stress disorder (PTSD)."

Cleveland Clinic: "Emotional Stress: Warning Signs, Management, When to Get Help," "Stress Nausea: Why It Happens and How To Deal. "

Johns Hopkins Medicine: "Signs of Respiratory Distress."

Helpguide.org: "Stress Symptoms, Signs, and Causes," "Understanding Stress."

Yale Medicine: "Chronic Stress."

Department of Health and Human Services: "Stress and Your Health."

American Institute of Stress: "Effects of Stress."

How to Feel Better in Less Than 15 Minutes

Need a quick pick-me-up? These simple steps can get you moving and boost your mood - fast!

Heart-Pounding, Stomach-Knotting: Stress and You

From knots in your stomach to headaches, heartburn and chronic health conditions, stress can lead to a variety of health issues.

Ways to Practice Self-Care

Self-care doesn't have to cost a lot. These simple steps can boost your mood and get you moving.

Natural Remedies to Alleviate Anxiety

These natural remedies can help ease your anxiety. Learn how they work - and when to see a doctor.

Is My Stress Level Too High?

From pain to digestive problems and more, the signs and symptoms of too much stress are easy to spot - once you know what to look for.

The Hidden Suffering of Social Anxiety Disorder

• Nidal Moukaddam, MD, PhD

Social anxiety disorder: increased screening and recognition are essential for proper diagnosis, and psychotropic and psychotherapeutic options can be effective.

DimaBerlin/AdobeStock

TALES FROM THE CLINIC

In this installment of Tales From the Clinic: The Art of Psychiatry , we examine a case of social anxiety disorder (SAD), an underappreciated entity that is often confused with shyness and temperamental disposition. SAD is common and thought to rank third among psychiatric conditions, after depressive and addictive disorders, worldwide; however, it is often challenging to diagnose because social interactions are heavily modulated by cultural and gender considerations as well as setting-specific considerations including work and school expectations.

Case Vignette

“Damien” is a 27-year-old medical trainee who presents to the clinic with the complaint of anxiety exacerbated by social situations. He outlines anxiety that he noted as early as age 10 years: “We have a big family, lots of uncles, aunts, cousins. Going into those gatherings was always so hard even though everyone there cared—and I have known them all since birth.” In high school, he had excellent grades but struggled when he tried taking a communications elective and recalls panic symptoms before a group presentation: “I had sweaty palms and my heart was skipping. I could not collect my thoughts; I must have looked like an idiot.”

The solution Damien devised for this type of situation was to be the notetaker for the group, who prepared PowerPoints and did background work. That way, he felt he was still participating and his work was appreciated, but he did not have to be in the spotlight. He did experience further challenges when he tried to ask someone out on a date, and when he had trouble placing his food order in front of others in a restaurant. He jokingly adds that being a medical student helps as he can always pretend he is busy, instead of saying he feels uncomfortable in social gatherings. He answers by text rather than calling when he has the chance. Other specific situations included difficulty calling to schedule his own medical appointments and going through mock examinations. He finds introducing himself to patients to be challenging and feels his voice is shaky when he presents in rounds.

Damien is presenting to care because he feels his symptoms have brought about significant impairment in his social life and career, preventing him from meeting new friends and from expanding his scholarly activities as he cannot present his research findings for fear of getting panicky.

Defining Social Anxiety

Figure 1. Examples of Situations That Can Trigger Social Anxiety

Social anxiety refers to the anxiety occurring directly in conjunction with social situations and the fear of being scrutinized in those situations. The gamut of situations that could trigger social anxiety ranges from meeting or talking to unfamiliar individuals, to presenting or performing in front of others, to acts that are seemingly mundane such as eating with others present ( Figure 1 ). Some anxiety in social situations may be situation-congruent (eg, major presentation that could determine a promotion), but the core of SAD is the underlying layer of negative cognition suggesting to the beholder that they will be judged, ridiculed, or otherwise negatively perceived. A traumatic experience in social settings is not needed as antecedent of SAD, and the disorder is far-reaching, causing impairment in multiple life functional areas. A duration of 6 months is needed for an SAD diagnosis as per the DSM-5 .

As with other anxiety disorders, clinical manifestations must be considered within developmental stage parameters. For instance, in a child, SAD may manifest as refusal to go to school, thereby raising the possibility of a separation anxiety disorder. In a teenager or young adult, SAD may interfere with asking others out or engaging with new friends (eg, when starting a new sport or moving to middle/high school or college). In individuals with medical conditions with noticeable movement abnormalities or postaccident/postsurgery disfigurement, some anxiety about interacting with others is common, and the diagnosis of SAD can only be applied in those situations where the anxiety is excessive or unrelated. SAD also includes paruresis, the fear of urinating in a public bathroom.

Figure 2. Global and Lifetime Prevalence of SAD

The prevalence of SAD in the US is about 7%, with higher prevalence in women than men. 1 SAD has a global prevalence ranging from 5% to 10% and a lifetime prevalence of 8.4% to 15% ( Figure 2 ). The prevalence rose slowly from the 1960s to the early 2000s with a preponderance in married, more educated populations. 2 The relationship between SAD and problematic internet use is not well understood but a small study in medical students has shown an association between anxiety and excessive internet usage. 3 Using alcohol or substances before or during events to mitigate distress is common, as is blushing, a hallmark physiological response of SAD. 4

According to the DSM-5 , SAD can have a subtype of performance-only anxiety, which is given when the fear is restricted to speaking or performing in public. This fear could be particularly impairing if/when school or work requires performance in front of others, such as in public speaking class or a musical performance.

Avoidance of the feared situation is a common feature of SAD. In history taking for the patient, it is essential to ask about what situations were missed because of fear, and what the costs of those avoidant behaviors have been, professionally and personally, for the individual. Less severe manifestations include a high level of anticipatory anxiety, overpreparation, or only joining the event with a companion or some assistance.

Screening for comorbid conditions is essential, and clinicians should inquire about other anxiety disorders, alcohol or other substance use, and mood disorders, especially depression. Diagnosis of SAD is facilitated by the Social Phobia Inventory and the Liebowitz Social Anxiety Scale.

Management strategies for SAD involve a combination of 2 primary treatment approaches, namely psychotherapy and focused pharmacologic intervention. Treatment also varies between adults and children/adolescents. Details outlining each treatment strategy are delineated here and in Figure 3 .

Figure 3. Brief Treatment Algorithm for SAD

Psychotherapeutic Intervention

Cognitive behavior therapy (CBT) remains the recommended first-line psychotherapeutic intervention for SAD in both adults and younger patients. There are also mindfulness and acceptance-based therapies, which include acceptance and commitment therapy, mindfulness-based stress reduction, and in vivo exposure—all of which aim to provide disconfirming evidence for cognitive distortions related to social expectations. The focus in adults is on guided interactive sessions between the psychiatrist and the patient, but in younger patients, parents are included in the physician-patient interaction. 5,6

Typically, 15 to 20 CBT sessions are administered ranging from 1 to 1.5 hours in length focusing on a multitude of practices: gradual exposure to social situations that incite fear after preparation of a rank-ordered list of such scenarios, with the least terror-inducing situation being the point of initiation in order to achieve habituation and extinction that lead to reductions in fear 7 ; exercises emphasizing cognitive restructuring before and after said exposures, which have been demonstrated to reduce social phobia and promote positive cognition 8 ; alteration of strongly held core beliefs that have been shown to improve quality of life in patients with social phobias 9 ; and the prevention of relapse to following avoidant behaviors. In young individuals, additional focus on parental education about the disorder is applied and parents are taught how to reinforce acceptable ways of addressing anxiety-inducing situations. Variations of CBT with social skill training are also included in the management plan. 10

Pharmacologic Interventions

First-line pharmacotherapies that have clearly demonstrated efficacy in reducing social anxiety and improving quality of life include selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors such as paroxetine, sertraline, fluvoxamine, and venlafaxine. Citalopram, escitalopram, and vilazodone have also shown promise, and seem to be more effective than fluoxetine. Minimum treatment durations of 4 to 6 weeks are needed for notable benefit. Paroxetine and sertraline are the most impactful drugs in the treatment of SAD owing to their exceptional relapse prevention rates, 11 and a 10- to 50-mg/d dose of paroxetine is considered the gold standard in producing the best response rates (> 50%) if overall adverse effects are taken into account. 12 Although some clinical studies have shown monoamine oxidase inhibitors like phenelzine to possess astounding response rates (> 80%), the diverse host of adverse effects attributed to them prevents them from being recommended as a first-line option. 13

Combination

Finally, although psychotherapy and pharmacologic intervention are rarely combined for the treatment of SAD, evidence demonstrating the benefit of combination CBT and paroxetine is beginning to accumulate and it would not be surprising to see future guidelines reflect these changes. 14 A major change in the treatment of SAD could be brought about by the recent positive results of nasal antianxiolytics such as PH94B/fasedienol: antidepressant and antianxiolytic effects of pherine molecules can provide a short-acting, as needed, treatment tool to be used before anxiety-provoking situations. Pherine molecules (neuroactive steroids), when sprayed intranasally, interface with the olfactory bulb which then feedback into γ-aminobutyric acid and corticotropin-releasing hormone neurons in the limbic amygdala. 14

Concluding Thoughts

SAD is a common and significant disorder that carries silent suffering, and contributes to depression, underemployment, and overall lack of ability of achieving one’s socioeducational potential. Increased screening and recognition are essential for proper diagnosis, and psychotropic and psychotherapeutic options can be effective.

Dr Altai is a resident at the University of California, San Francisco. Dr Chaudhry is a graduate of and research associate at the Aga Khan University in Karachi, Pakistan. Dr Moukaddam is an associate professor in the Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, in Houston, Texas, as well as the Ben Taub Adult Outpatient Services director and the medical director of the Stabilization, Treatment & Rehabilitation (STAR) Program for Psychosis, also at Baylor College of Medicine. She also serves on the  Psychiatric Times  Editorial Board.

1. Ruscio AM, Brown TA, Chiu WT, et al. Social fears and social phobia in the USA: results from the National Comorbidity Survey Replication. Psychol Med . 2008;38(1):15-28.

2. Heimberg RG, Stein MB, Hiripi E, Kessler RC. Trends in the prevalence of social phobia in the United States: a synthetic cohort analysis of changes over four decades. Eur Psychiatry . 2000;15(1):29-37.

3. Melca IA, Teixeira EK, Nardi AE, Spear AL. Association of internet addiction and mental disorders in medical students: a systematic review. Prim Care Companion CNS Disord . 2023;25(3):22r03384.

4. Bögels SM, Alden L, Beidel DC, et al. Social anxiety disorder: questions and answers for the DSM-V. Depress Anxiety . 2010;27(2):168-189.

5. Butler RM, O’Day EB, Swee MB, et al. Cognitive behavioral therapy for social anxiety disorder: predictors of treatment outcome in a quasi-naturalistic setting. Behav Ther . 2021;52(2):465-477.

6. Melfsen S, Kühnemund M, Schwieger J, et al. Cognitive behavioral therapy of socially phobic children focusing on cognition: a randomised wait-list control study. Child Adolesc Psychiatry Ment Health . 2011;5(1):5.

7. Jeong HS, Lee JH, Kim HE, Kim JJ. Appropriate number of treatment sessions in virtual reality-based individual cognitive behavioral therapy for social anxiety disorder. J Clin Med . 2021;10(5):915.

8. Taylor S, Woody S, Koch WJ, et al. Cognitive restructuring in the treatment of social phobia. Efficacy and mode of action. Behav Modif . 1997;21(4):487-511.

9. Leigh E, Clark DM. Cognitive therapy for social anxiety disorder in adolescents: a development case series. Behav Cogn Psychother . 2016;44(1):1-17.

10. Powell VB, Oliveira OH, Seixas C, et al. Changing core beliefs with trial-based cognitive therapy may improve quality of life in social phobia: a randomized study. Braz J Psychiatry . 2013;35(3):243-247.

11. Sanchez C, Reines EH, Montgomery SA. A comparative review of escitalopram, paroxetine, and sertraline: are they all alike? Int Clin Psychopharmacol . 2014;29(4):185-196.

12. Stein MB, Liebowitz MR, Lydiard RB, et al. Paroxetine treatment of generalized social phobia (social anxiety disorder): a randomized controlled trial. JAMA . 1998;280(8):708-713.

13. Versiani M, Nardi AE, Mundim FD, et al. Pharmacotherapy of social phobia. A controlled study with moclobemide and phenelzine. Br J Psychiatry . 1992;161:353-360.

14. Monti L, Liebowitz MR. Neural circuits of anxiolytic and antidepressant pherine molecules. CNS Spectr . 2022;27(1):66-72.

The Perinatal Mental Health Crisis

5 Personality Traits of Olympic Athletes

WHO Addresses Gaps in Mental Health Care Delivery and Quality

Teamwork and Trauma: a Conversation With Kasey Grewe, MD, and Niesha Voigt, MD

Unraveling the Threads of Trepidation: The Prevalence and Evolving Contours of Anxiety and Traumatic Stress

What Have We Learned About Trauma and Stress Over the Years?

2 Commerce Drive Cranbury, NJ 08512

609-716-7777

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings
• My Bibliography
• Collections
• Citation manager

Save citation to file

Email citation, add to collections.

• Create a new collection
• Add to an existing collection

Add to My Bibliography

Your saved search, create a file for external citation management software, your rss feed.

• Search in PubMed
• Search in NLM Catalog
• Add to Search

Difficult decision-making in major depressive disorder: Practical guidance based on clinical research and experience

Affiliations.

• 1 Academic Department of Psychiatry, Faculty of Medicine and Health, Kolling Institute, Northern Clinical School, The University of Sydney, Sydney, New South Wales, Australia.
• 2 CADE Clinic and Mood-T, Royal North Shore Hospital, Northern Sydney Local Health District, St. Leonards, New South Wales, Australia.
• 3 Department of Psychiatry, University of Oxford, Oxford, UK.
• 4 Faculty of Health and Medical Sciences, University of Western Australia, Perth, Western Australia, Australia.
• 5 Discipline of Psychiatry, Faculty of Medicine and Health, Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia.
• 6 Department of Psychiatry, University of Melbourne and Professorial Psychiatry Unit, Albert Road Clinic, Melbourne, Victoria, Australia.
• 7 Department of Psychological Medicine, University of Otago, Christchurch, New Zealand.
• PMID: 37258062
• DOI: 10.1111/bdi.13350

Objectives: To extend current published guidance regarding the management of major depression in clinical practice, by examining complex cases that reflect real-world patients, and to integrate evidence and experience into recommendations.

Methods: The authors who contributed to recently published clinical practice guidelines were invited to identify important gaps in extant guidance. Drawing on clinical experience and shared knowledge, they then generated four fictional case studies to illustrate the real-world complexities of managing mood disorders. The cases focussed specifically on issues that are not usually addressed in clinical practice guidelines.

Results: The four cases are discussed in detail and each case is summarised using a life chart and accompanying information. The four cases reflect important real-world challenges that clinicians face when managing mood disorders in day-to-day clinical practice. To partly standardise the presentation of each case and for ease of reference we provide a Time Line, History Box and Management Chart, along with a synopsis where relevant. Discussion and formulation of the cases illustrate how to manage the complexities of each case and provide one possible pathway to achieving functional recovery.

Conclusion: These cases draw on the combined clinical experience of the authors and illustrate how to approach diagnostic decision-making when treating major depressive disorder and having to contend with complex presentations. The cases are designed to stimulate discussion and provide a real-world context for the formulation of mood disorders.

Keywords: depression; guidelines; treatments.

© 2023 The Authors. Bipolar Disorders published by John Wiley & Sons Ltd.

PubMed Disclaimer

Similar articles

• Letter to the Editor: CONVERGENCES AND DIVERGENCES IN THE ICD-11 VS. DSM-5 CLASSIFICATION OF MOOD DISORDERS. Cerbo AD. Cerbo AD. Turk Psikiyatri Derg. 2021;32(4):293-295. doi: 10.5080/u26899. Turk Psikiyatri Derg. 2021. PMID: 34964106 English, Turkish.
• Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders. Malhi GS, Bassett D, Boyce P, Bryant R, Fitzgerald PB, Fritz K, Hopwood M, Lyndon B, Mulder R, Murray G, Porter R, Singh AB. Malhi GS, et al. Aust N Z J Psychiatry. 2015 Dec;49(12):1087-206. doi: 10.1177/0004867415617657. Aust N Z J Psychiatry. 2015. PMID: 26643054 Review.
• The 2020 Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders: Major depression summary. Malhi GS, Bell E, Singh AB, Bassett D, Berk M, Boyce P, Bryant R, Gitlin M, Hamilton A, Hazell P, Hopwood M, Lyndon B, McIntyre RS, Morris G, Mulder R, Porter R, Yatham LN, Young A, Murray G. Malhi GS, et al. Bipolar Disord. 2020 Dec;22(8):788-804. doi: 10.1111/bdi.13035. Bipolar Disord. 2020. PMID: 33320412 Review.
• The use of lithium for the treatment of bipolar disorder: Recommendations from clinical practice guidelines. Malhi GS, Gessler D, Outhred T. Malhi GS, et al. J Affect Disord. 2017 Aug 1;217:266-280. doi: 10.1016/j.jad.2017.03.052. Epub 2017 Mar 27. J Affect Disord. 2017. PMID: 28437764 Review.
• [Alpha-interferon and mental disorders]. Debien C, De Chouly De Lenclave MB, Foutrein P, Bailly D. Debien C, et al. Encephale. 2001 Jul-Aug;27(4):308-17. Encephale. 2001. PMID: 11686052 Review. French.
• Malhi GS, Mann JJ. Depression. Lancet. 2018;392(10161):2299-2312.
• Malhi GS, Bell E, Bassett D, et al. The 2020 Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders. Aust N Z J Psychiatry. 2021;55(1):7-117.
• Malhi GS, Bell E, Singh AB, et al. The 2020 Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders: major depression summary. Bipolar Disord. 2020;22(8):788-804.
• Malhi GS, Bell E, Boyce P, et al. The 2020 Royal Australian and New Zealand college of psychiatrists clinical practice guidelines for mood disorders: bipolar disorder summary. Bipolar Disord. 2020;22(8):805-821.
• NICE. Depression in Adults: Treatment and Management. NICE Guideline No. NG222. National Institute for Health Care Excellence; 2022.

Publication types

• Search in MeSH

Related information

Linkout - more resources, full text sources.

• Ovid Technologies, Inc.
• Genetic Alliance
• MedlinePlus Consumer Health Information
• MedlinePlus Health Information

• Citation Manager

NCBI Literature Resources

MeSH PMC Bookshelf Disclaimer

The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). Unauthorized use of these marks is strictly prohibited.

• Open access
• Published: 19 August 2024

Deliberate self-harm in adolescents screening positive for attention-deficit / hyperactivity disorder: a population-based study

• Amalie Austgulen 1 ,
• Maj-Britt Posserud 2 , 3 ,
• Mari Hysing 4 , 5 ,
• Jan Haavik 1 , 6 &
• Astri J. Lundervold 7  

BMC Psychiatry volume  24 , Article number:  564 ( 2024 ) Cite this article

Metrics details

Adolescents with attention-deficit / hyperactivity disorder (ADHD) have an increased risk of self-harm. The risk of self-harm among adolescents who display an elevated level of ADHD symptoms, but without a formal diagnosis, is not well-studied and understood.

To investigate the relationship between self-reported symptoms of ADHD and self-harm in a population-based sample of adolescents.

Adolescents in the population-based youth@hordaland study were invited to complete the Adult ADHD Self-Report Scale (ASRS) and the Short Mood and Feelings Questionnaire (SMFQ). They were asked whether they ever deliberately have taken an overdose or tried to harm themselves on purpose, once or multiple times, defined according to the code used in the Child and Adolescent Self-harm in Europe (CASE) Study. Adolescents reporting severe problems on ≥ four of six selected items on the ASRS-v 1.1 screener were defined as ADHD-screen positive (ADHD-SC+), and the remaining sample as ADHD-screen negative (ADHD-SC-). SMFQ score ≥ 12 was used to define a high level of depressive symptoms.

A total of 9692 adolescents (mean age 17.4 years, 53.1% females) participated in the study, of which 2390 (24.7%) screened positive on the ASRS. ADHD-SC+ adolescents engaged in self-harm more often than the ADHD-SC- group (14.6% vs. 5.4%, OR = 3.02, 95%CI [2.57–3.24]). This remained significant after adjustment for demographic variables, SMFQ score ≥ 12, symptoms of conduct disorder and familial history of self-harm and suicide attempts (OR = 1.58, 95%CI [1.31–1.89]). They were also more likely to report an overdose as their method of self-harm (OR = 1.52, 95%CI [1.05–2.23]). Within the ADHD-SC+ group female sex, high levels of inattention and hyperactivity/impulsivity symptoms, SMFQ score ≥ 12, symptoms indicating conduct disorder and familial history of self-harm and suicide attempts increased the likelihood of engaging in deliberate self-harm.

Adolescents who screened positive for ADHD had increased risk of engaging in self-harm. Clinicians should consider the increased risk of such engagement in adolescents who present with high level of ADHD symptoms, even in the absence of a clinical ADHD diagnosis.

Peer Review reports

Introduction

Self-harming behaviors are common among adolescents and have been shown to increase future risk of suicide [ 1 , 2 , 3 , 4 ]. The risk of self-harm is notably elevated among persons with a diagnosis of attention-deficit/hyperactivity disorder (ADHD) [ 1 ]. Less is known about the risk of self-harm in adolescents who display elevated levels of ADHD symptoms in the general population.

ADHD is a childhood-onset neurodevelopmental disorder, with symptoms that often continue throughout adolescence and adulthood. In Norway, approximately 4% of adolescents at age 16 are diagnosed with ADHD, with the highest prevalence in boys (5.5%) [ 5 ]. Core symptoms include inattention, hyperactivity, and impulsivity [ 6 ], but individuals with ADHD also frequently struggle with emotion regulation [ 7 , 8 , 9 ], high levels of stress, poor executive functioning [ 10 , 11 ], and comorbid psychiatric disorders [ 12 ]. Together, this may lead to challenges affecting quality of life, academic and occupational functioning, and social relationships [ 13 , 14 , 15 , 16 , 17 ]. Individuals with ADHD are also at increased risk of accidents and injuries [ 18 ], including deliberate self-harm.

Self-harm is defined as intentional self-inflicted destruction of one’s body, and is often classified as non-suicidal self-injury (NSSI) if there is no suicidal intent present [ 19 ]. The estimated prevalence is 16.2% in a Norwegian population-based sample of adolescents, with similar prevalence rates reported worldwide, making self-harm a major public health problem in this age group [ 20 , 21 ]. In recent years, several reviews and large cohort studies have established a positive association between ADHD and both self-harm and suicide attempts [ 1 , 22 , 23 , 24 , 25 , 26 ]. In population-based studies, adolescents and young adults with ADHD face a heightened risk of self-harm when compared to their peers without the diagnosis [ 27 , 28 , 29 ]. Furthermore, a study investigating a nationally representative sample of Australian youths found that even adolescents with subthreshold ADHD had an increased risk of NSSI [ 30 ]. Previous studies have proposed several important risk factors in the association between ADHD and both self-harm and suicide, including higher levels of ADHD symptoms, female sex, and psychiatric comorbidities, such as depression, bipolar disorder, and substance use disorder [ 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 ].

While ADHD is more commonly diagnosed in males than females, there is conflicting evidence regarding the role of sex differences in the risk of self-harm. A clinical study investigating psychiatric inpatient adolescents found that an ADHD diagnosis was associated with a high likelihood of NSSI, especially in girls [ 45 ]. In a case series analyzing adolescents presenting with self-harm at emergency departments, hyperactivity and emotional problems, as measured by the Strengths and Difficulties Questionnaire (SDQ), were found to be significantly higher than in a reference group. Since the sample consisted of 78% females, ADHD symptoms were suggested to be a potential mechanism of recurrent self-harm in female adolescents [ 46 ]. Another study found no significant effects of sex on self-harm in a clinical sample of Canadian children and adolescents with ADHD [ 47 ]. This highlights the undetermined significance of ADHD symptoms, which could have potentially different clinical implications in relation to self-harm in males and females.

There is some conflicting evidence regarding the relative importance of each symptom domain of ADHD in relation to self-harm. Recently, it was observed that inattention in childhood was closely associated with NSSI at 15 years of age, which was not the case for childhood impulsivity or hyperactivity [ 48 ]. This was also explored in the Berkeley Girls with ADHD Longitudinal Study (BGALS), where both inattention and hyperactivity / impulsivity symptoms were more severe in adolescent girls who had a history of NSSI [ 32 ]. On the other hand, a cross-sectional study investigating a clinical sample of 1006 Canadian children and youth indicated that a selection of hyperactivity-impulsivity symptoms, but not inattention, were associated with NSSI [ 49 ]. In adults with ADHD who presented with self-harm at Swedish hospitals, impulsivity was not found to be a significant predictor of self-harm, but this was after adjustments for a clinical diagnosis of depression and emotionally unstable personality disorder, sex, and age [ 42 ].

Self-harm in adolescents is often associated with higher severity levels of depressive symptoms [ 4 , 21 ], and depression is a common comorbid disorder in individuals with ADHD [ 37 , 39 , 40 , 50 ]. A study utilizing population-based data from the youth@hordaland study found that each severe ADHD symptom, as reported on the Adult ADHD Self-Report Scale (ASRS), significantly contributed to an increase in the score of depressive symptoms, measured by the Short Mood and Feelings Questionnaire (SMFQ) [ 51 ]. More than 20% of those who were defined as depressed reported six or more symptoms of inattentiveness, suggesting a strong link between a diagnosis of ADHD and depression, particularly in females. In males, symptoms of hyperactivity and impulsivity have been suggested to be closely associated with externalizing disorders through shared developmental pathways, predisposing vulnerabilities, and environmental influences [ 52 ].

The role of comorbidities in predicting self-harm in adolescents is still not fully understood, but several large cohort studies have shown that the association between ADHD and self-harm remains statistically significant even after adjustments for the presence of comorbid psychiatric disorders [ 39 , 40 , 42 , 50 , 53 ]. However, other studies have reported conflicting results, as symptoms of comorbid conditions in both sexes have been found to fully mediate the relationship between symptoms of ADHD and the presence of NSSI [ 45 ]. Additionally, findings from a population-based study in Denmark indicate that individuals with ADHD have a higher risk of suicidal behavior when a family history of psychiatric disorders or suicidal behaviors is present [ 37 ]. This highlights the significance of considering comorbid symptoms not only in individuals with ADHD, but also in their family members.

In previous literature, the association between ADHD and suicidal behavior has been studied extensively [ 22 , 23 , 25 , 26 , 54 ]. The majority of these studies have included clinical samples. However, there is still a need for more information regarding self-harm in adolescents who exhibit elevated levels of ADHD symptoms, especially on a population-based level. Since both ADHD symptoms and self-harm are especially prevalent in this age group, more information on their interaction could improve the understanding of this relationship and possible implications.

The aim of the present study was to investigate the relationship between self-reported symptoms of ADHD and self-harm in a population-based sample of adolescents. First, we sought to estimate the prevalence of adolescents engaged in self-harm across ADHD screening status. Furthermore, we investigated how factors such as sex, inattentive and hyperactivity/impulsivity symptoms, symptoms of depression and conduct disorder, as well as familial history of self-harm and suicide attempts, affected the likelihood of engaging in self-harm, both once and multiple times, in a non-clinical sample of adolescents who screen positive for ADHD.

Study design

The present study included data from the cross-sectional population-based study youth@hordaland. The overall aim of the youth@hordaland study was to gather information about mental health problems, lifestyle factors, and service use among adolescents living in Hordaland County in Norway.

All adolescents born between 1993 and 1995, and all students attending upper secondary education between January and May 2012 who were living in Hordaland County in Norway, were invited to participate in the study (19 439). They received information by email, followed by an SMS reminder. All upper secondary schools in the county participated, and the adolescents were allocated time during regular school hours to complete the electronic questionnaire. A teacher was present to organize the data collection and ensure confidentiality.

For the adolescents who were not at school during the allocated time, the questionnaires could be completed at other times during the study period, and some schools arranged new days for catch-up. Those who were in hospitals or institutions were also invited to participate, and arrangements were made to make participation possible. Adolescents not in schools received information by postal mail to their home addresses.

The study was approved by the Regional Committee for Medical and Health Research Ethics (REC) in Western Norway. All adolescents consented to participation in the current study, in accordance with Norwegian regulations stating that adolescents aged 16 and older can make decisions regarding their own health, including participation in health studies. The parents or guardians received written information about the study in advance.

Age and biological sex

Biological sex and date of birth were identified through the personal identification number in the Norwegian National Population Register. We use the term biological sex when referring to males and females in the present study, though the identified gender of the participants may vary. The age at completion was defined by calculating the time interval between the date of participation and the date of birth.

Socioeconomic status (SES)

SES was assessed by adolescent report of parental education for the mother and father, with the response options: “Primary school or similarly”, “Secondary school, vocational”, “Secondary school, general”, “College or university, less than 4 years”, “College or university, more than 4 years” and “do not know”. The two secondary school categories were combined, as well as the categories regarding college or university.

Symptoms of ADHD

The Adult ADHD Self-Report Scale (ASRS) was used to assess the presence and severity of ADHD symptoms [ 55 ]. This questionnaire is intended for use in adults above the age of 18 but has also been validated in samples of adolescents [ 56 , 57 ]. It consists of 18 items, with nine items assessing symptoms of hyperactivity/impulsivity (HI) and nine items assessing inattention (IN). The response options are “Never”, “Rarely”, “Sometimes”, “Often” and “Very often”, with scores from 0 to 4. The ASRS has a high internal consistency and has been validated in population-based studies [ 58 ].

The first six questions in the ASRS constitute the screener version of the questionnaire, ASRS v 1.1 Screener [ 55 ]. Answers “Often” and “Very often”, as well as “Sometimes” on items 1–3, are defined as symptoms highly consistent with ADHD [ 55 ]. A score of four or more is indicative of a positive screening for ADHD [ 58 , 59 ]. This cut-off was used in the present study, with those scoring above being defined as ADHD-screen positive (ADHD-SC+), and the remaining sample as ADHD-screen negative (ADHD-SC-).

In the 18-item ASRS Symptom Checklist (ASRS-18), IN symptoms were defined as severe if reported to be present “Often” or “Very often” on items 1–4 and 7–11, with the addition of “Sometimes” on items 1–3 and 9. Similarly, HI symptoms were defined as severe if participants responded “Often” or “Very often” on items 5–6 and 12–18, with the addition of “Sometimes” on items 12, 16 and 18 [ 55 ]. The total number of symptoms at this level was calculated separately for the IN and the HI subscale (0–9) and used to define symptom severity.

The Diagnostic and Statistical Manual of Mental Disorders , fifth edition (DSM-5) criteria for ADHD states that children and adolescents under the age of 17 are defined as having high levels of IN or HI if they have 6 or more symptoms of either symptom dimension. For adolescents and adults who are 17 and older, 5 or more symptoms are defined as sufficient. Scores above these cut-offs were used to define a high level of IN or HI symptoms and were applied to select the most affected adolescents in terms of ADHD symptoms.

Self-reported ADHD, ADD, and problems with concentration

Participants were asked whether they had received a diagnosis of either ADHD, attention-deficit disorder (ADD), or problems with concentration, not otherwise specified, by a clinical professional.

Symptoms of depression

Symptoms of depression were assessed by the Short Version of the Mood and Feelings Questionnaire (SMFQ) [ 60 ], which consists of 13 items. The items assess the presence of emotional and cognitive symptoms associated with depression experienced by an individual in the past two weeks, rated on a 3-point Likert scale. SMFQ has shown good psychometric properties and high internal consistency between items in population-based studies [ 61 , 62 , 63 , 64 ], and has been validated in a study including a sample from youth@hordaland [ 65 ].

The total SMFQ score ranges from 0 to 26. In a study examining the reliability and validity of the original and short version of MFQ in adolescents, the optimal cut-off value for differentiating depressed from nondepressed cases was ≥ 12 [ 66 ]. This cut-off has also been suggested for young adults [ 67 ], while other studies have favored a cut-off score of 11 in this age group [ 68 , 69 , 70 ]. In the current study, an SMFQ score of 12 and above was used to dichotomize the adolescents into “low/medium level of depressive symptoms” and “high level of depressive symptoms”.

Symptoms of conduct problems

The Youth Conduct Disorder (YCD) scale was used to assess symptoms of conduct problems. This questionnaire is a part of the Diagnostic Interview Schedule for Children Predictive Scales (DPS), which is shown to identify adolescents with a high probability of meeting the diagnostic criteria of conduct disorder [ 71 ]. It consists of 8 items covering behaviors such as shoplifting, school expulsion, theft from others, animal cruelty and vandalizing or breaking into the property of others. The response options are “yes” and “no”. In the present study, responses on YCD were dichotomized to having no symptoms of conduct disorder (total score of 0) and presence of conduct problems (total score of 1 or above).

Self-harm in participants

To assess whether the adolescents had engaged in self-harm, they were asked the following question: “Have you ever deliberately taken an overdose (e. g., pills or other medication) or tried to harm yourself in some other way (such as cut yourself)?”, which is an item included in the Child and Adolescent Self-harm in Europe Study (CASE) [ 72 ]. If participants answered “Yes”, they were asked to complete the following item: “Describe what you did to yourself on that occasion. Please give as much detail as you can - for example, the name of the drug taken in an overdose.” If they had engaged in self-harm more than once, they were asked to report the last time they had harmed themselves.

After the data collection was finished, two coders classified all “yes” answers into “self-harm case” (SH-case), “not SH-case” and “no information on self-harm”. This was done according to the CASE guidelines, defining self-harm as an: “act with a non-fatal outcome in which an individual deliberately did one or more of the following: initiated behavior (e.g., self-cutting, jumping from a height), which they intended to cause the self-harm; ingested a substance in excess of the prescribed or generally recognized therapeutic dose; ingested a non-ingestible substance or object.”. Frequency of self-harm was recorded and coded as follows: “none”, “once”, “two or more times” [ 4 ].

In the present study, all participants with answers classifying them as SH-cases were determined to be valid cases, while those who were classified as “not SH-case” and “no information on self-harm” were included in a non-case group together with those who answered “no” on the item assessing self-harm (no-case). Those without any data on self-harm were removed from the sample before the conduction of the statistical analyses. When coding the 908 adolescents who answered yes to having harmed themselves or taken an overdose, 35 (3.9%) were defined as not valid cases of SH from the description given, while 122 (13.4%) adolescents did not give enough information to correctly classify the case according to the CASE guidelines. All SH cases were also coded according to the method used to define self-harm. Due to a limited number of cases using other forms of self-harming methods, only adolescents reporting overdose and/or self-cutting were investigated in this study.

Self-harm in family members

Participants were asked: “Have someone in your family ever tried to take their own life or harm themselves on purpose?”, with the response alternatives “No”, “Yes, more than a year ago”, and “Yes, lately”, taken from the CASE study [ 72 ]. The last two categories were combined in statistical analyses.

Statistical analyses

The data was analyzed using R (version 4.1.3) [ 73 ]. First, we investigated differences in characteristics based on the screening status of the adolescents. Afterward, the association between ADHD screening status and self-harm was explored. We conducted a logistic regression model, with ADHD screening status as the exposure variable, and SH-case versus no-case as the outcome variable. The model was adjusted for age, sex (with male as reference), parents’ level of education (with primary school as reference), SMFQ ≥ 12, YCD ≥ 1, and the familial history of self-harm or suicide attempts. Only participants with complete answers on all measures were included in this model. To investigate differences in characteristics of self-harm, odds ratios (OR) were estimated for those who were ADHD-SC+, with ADHD-SC- as reference. Within the ADHD-SC + group, the same method for estimating ORs was used to explore differences in characteristics between SH cases and non-cases. This was done utilizing the R packages finalfit and knitr [ 74 , 75 , 76 , 77 ].

Out of 19 439 invited adolescents, 10 257 (53%) consented to participate in the study. Among those, 460 (4.5%) adolescents did not complete the ASRS screener version, while 457 (4.5%) did not present complete data on the presence of self-harm. Of those, 352 adolescents had missing data on both measures (Fig.  1 ). A total of 565 adolescents were removed, constituting the majority of missing variables in the data set (data not shown). The final study sample included 9 692 adolescents, with a mean age of 17.4 years (age range 16–19 years) and comprised of 5165 (53%) females.

When investigating the study sample, 2390 (24.7%) adolescents screened positive on the ASRS-v.1.1 and were categorized as ADHD-SC+. The remaining adolescents ( N  = 7302) were defined as ADHD-SC- (Fig.  1 ).

Overview of participants included in the study. ADHD: Attention-deficit / hyperactivity disorder, ASRS: Adult ADHD Self-Report Scale

A diagnosis of ADHD was reported by 127 adolescents, while 55 reported having attention-deficit disorder (ADD) and 7 reported problems with concentration, not otherwise specified. Out of the 127 adolescents who reported ADHD, 67 (53%) screened positive on the ASRS. This was also the case for 35 (64%) of the adolescents who reported ADD, and 7 (100%) of those who reported problems with concentration.

Descriptive characteristics

The descriptive characteristics of the sample are presented in Table  1 .

Among adolescents who engaged in self-harm ( N  = 745), there were a higher proportion of females (82% vs. 51%, p  < 0.001), a positive ADHD screening status (47% vs. 23%, p  < 0.001), and a score of 12 or more on the SMFQ (52% vs. 13%, p  < 0.001), when compared to adolescents who reported no previous self-harm.

Females who screened positive for ADHD were more likely to report higher levels of IN symptoms (OR 1.56, 95%CI [1.30–1.88]) as well as a high SMFQ score (OR 2.45, 95%CI [2.09–2.88]) compared to their male counterparts. Additionally, ADHD-SC+ females were less likely to report symptoms of conduct disorder (OR 0.67, 95% [0.59–0.76]) than ADHD-SC+ males.

The association between ADHD screening status and self-harm

Adolescents defined as ADHD-SC+ were more often engaged in self-harm than the ADHD-SC- group (14.6% vs. 5.4%). When adjusting for sex, age and parents’ level of education, the likelihood of being defined reporting previous self-harm declined slightly. This was further attenuated when accounting for either the presence of conduct problems, a high SMFQ score (i.e., ≥ 12) or a familial history of self-harm (Table  2 ). In the fully adjusted model, those who were ADHD-SC+ still had a significantly higher risk of self-harm when compared to ADHD-SC- adolescents (Table  2 ).

20% of adolescents who reported either ADHD, ADD or problems with concentration ( N  = 37) had engaged in self-harm, a percentage that was similar to the prevalence rates found in the group of ADHD-SC+ adolescents.

Characteristics of self-harm

When analyzing adolescents who had engaged in self-harm, 415 (56%) reported engagement in self-harm two or more times, with no statistically significant differences between the ADHD screening groups (OR 1.25, 95%CI [0.93–1.67]). ADHD-SC+ adolescents were more likely to have taken an overdose (21% vs. 15%, OR 1.52, 95%CI [1.05–2.23]), when compared to other methods of self-harm, an association that was attenuated after adjustments for sex, age, and parents’ level of education (OR 1.47, 95%CI [1.00-2.16]). They were also less likely to choose self-cutting as their method (77% vs. 82%, OR 0.69, 95%CI [0.48–0.99]), but this did not remain significant after adjustments for age, sex, and SES. Further details are presented in Supplementary Table S1 .

Factors associated with self-harm in adolescents screening positive for ADHD

Adolescents defined as ADHD-SC+ who engaged in self-harm ( N  = 350) were more likely to be female, have severe and high levels of both IN and HI symptoms, as well as a high score on the symptom scales of depression and conduct disorder, when compared to those who did not engage in self-harm (Fig.  2 ). The risk estimates remained statistically significant after adjusting for age, biological sex, and parents’ levels of education (Supplementary Table S2 ). ADHD-SC+ adolescents who had parents with high education were less likely to engage in self-harm (Supplementary Table S2 ).

Factors associated with self-harm in ADHD-SC+ adolescents ( N  = 2390). ADHD: Attention-deficit / hyperactivity disorder, ADHD-SC+: Screen positives for ADHD, CI: Confidence interval, HI: Hyperactivity / impulsivity, IN: Inattention, SMFQ: Short Mood and Feelings Questionnaire, YCD: The Youth Conduct Disorder scale

Within the ADHD-SC+ group, having engaged in self-harm multiple times ( N  = 205), versus only once ( N  = 145), was associated with the total number of severe ADHD symptoms, number of severe HI and IN symptoms, high levels of HI symptoms, as well as high SMFQ score (≥ 12). Neither sex, high levels of IN symptoms nor symptoms of conduct disorder were significantly associated with engaging in self-harm multiple times (Fig.  3 ).

Factors associated with engaging in self-harm twice or more times, vs. only once, in ADHD-SC+ adolescents ( N  = 350). ADHD: Attention-deficit / hyperactivity disorder, ADHD-SC+: Screen positives for ADHD, CI: Confidence interval, HI: Hyperactivity / impulsivity, IN: Inattention, SMFQ: Short Mood and Feelings Questionnaire, YCD: The Youth Conduct Disorder scale

In this population-based study, we observed that adolescents who screened positive for ADHD had an increased risk of engaging in self-harm. This remained statistically significant after adjustments for age, biological sex, parents’ level of education, high levels of depressive symptoms, symptoms indicating a conduct disorder, and a familial history of self-harm and suicide attempts. Suggested risk factors for self-harm in adolescents defined as ADHD-SC+ included female gender, higher levels of inattention, hyperactivity/impulsivity, and depressive symptoms, as well as symptoms of conduct disorder and familial history of self-harm or suicide attempts.

We found that adolescents defined as ADHD-SC+ had three-fold higher odds of having engaged in self-harm than adolescents defined as ADHD-SC-. A similar risk estimate for NSSI was found in the BGALS sample, which included adolescent girls with and without an ADHD diagnosis [ 32 ]. In a population-based study from Finland, 69% of adolescents who engaged in self-harm were diagnosed with ADHD, with no significant differences when comparing ADHD combined or HI subtype [ 27 ]. Our results suggest an increased risk even among adolescents who have not received a clinical diagnosis but exhibit high levels of ADHD symptoms.

In this study, adolescents defined as ADHD-SC+ had a significantly increased risk of self-harm even when adjusting for demographic variables, symptoms of depression and conduct problems, as well as familial history of self-harm or suicide attempts. Adjustments for demographics and familial history of self-harm and suicide decreased the risk estimates slightly, while symptoms of conduct disorder and depression seemed to explain the association to a greater degree. This finding corresponds to the three-fold higher risk of suicide attempts found in a nationally representative sample of Canadian adults with an ADHD diagnosis, where the association decreased by 60% when adjusting for sociodemographic factors, learning disabilities, and lifetime history of mental illness. The present study suggests that this may also be the case for individuals who screen positive for ADHD in a population-based sample. Additionally, it supports the hypothesis that the risk of self-harm cannot be fully explained by the presence of sociodemographic factors, psychiatric comorbidities, and familial history of self-harming behaviors.

In ADHD-SC+ adolescents, we find that the number of severe IN and HI symptoms was associated with previous self-harm. This finding corresponds to results reported in the BGALS sample, where both the IN and HI symptom severity scores were significantly associated with NSSI and suicide attempts in girls with ADHD in adolescence and young adulthood [ 32 ]. However, the number of severe IN symptoms, as well as a high level of IN symptoms, seemed to increase the likelihood of having engaged in self-harm slightly more than HI symptoms in the present study.

When investigating self-harm only within the group of adolescents who screened positive for ADHD, female sex and symptoms of depression emerged as the strongest risk factors for self-harm, while higher socioeconomic status was associated with a decreased likelihood. Females in the ADHD-SC+ group were both more likely to have higher levels of IN and depressive symptoms, as well as a higher prevalence of self-harm, strengthening the hypothesis of a possible interaction. When investigating ADHD screening status as a predictor of self-harm, adjustments for demographic factors such as biological sex only decreased the estimates slightly. This suggests that sex differences do not account for the association between self-harm and ADHD screening status, though females are at a higher risk of self-harm in general. Higher levels of depressive symptoms accounted for a large proportion of the association, which is to be expected from previous literature. The high rates of comorbidity between ADHD and depression have been studied extensively, and symptoms of depression can often be linked to self-harm behaviors and suicidality in adolescents [ 3 , 45 , 78 ].

Impulsivity has been suggested as an important contributing factor to the increased risk of both self-harm and suicide in individuals with ADHD [ 37 , 54 ], hypothesizing that they are more likely to act on thoughts or impulses without considering the consequences. In early adolescence, the tendency to seek out novel, thrilling or risky situations is associated with onset of self-harm, while difficulties with planning and forethought predicted maintained self-harm [ 79 ]. This study supports previous findings, with both the number of HI symptoms as well as higher symptom levels contributing to an increased risk of reporting self-harm in ADHD-SC+ adolescents. Additionally, ADHD-SC+ adolescents who engaged in self-harm were more likely to have symptoms of conduct disorder, where impulsivity is thought to be a shared predisposing vulnerability [ 52 ].

Interestingly, higher levels of HI symptoms, but not IN symptoms, were significantly associated with engaging in self-harm multiple times. Our findings also indicate that adolescents in the ADHD-SC+ group were more likely to choose overdose as their method of self-harm, though the estimates are uncertain. It is plausible that adolescents who are more impulsive and hyperactive are more likely to choose more drastic methods for harming themselves and may have a higher incidence of self-harm with suicidal intent or severe consequences.

Questionnaires such as the ASRS provide a quick and cost-effective method for assessment of ADHD symptoms in clinical practice. Since adolescents are vulnerable to engaging in self-harm, a greater understanding of the role of reported ADHD symptoms is important in improving the development of prevention and intervention strategies. The current study highlights the importance of screening for ADHD in adolescents who are at risk of self-harm, as well as for self-harm in adolescents who have symptoms of ADHD. This is underlined by results showing that the association between self-harm and ADHD could not be fully explained by psychiatric comorbidities, biological sex, or familial history of self-harm, though all of these are important factors that increase the likelihood of self-harm in this age group.

Strengths and limitations

This is a population-based study with a large sample size, including multiple validated measures of mental health problems, which makes it possible to investigate associations with sufficient power. Nevertheless, several limitations should be noted. First, the data is of a cross-sectional nature, which does not make it possible to establish a temporal order and causal relationship between the variables. The participation rate of 53% could also have led to a sampling bias. In earlier waves of the current study, nonresponse has been linked to poorer mental health [ 80 ]. Therefore, the prevalence and estimates found could be underestimations. Although the estimates may deviate from reality, the correlation between symptoms of ADHD and self-harm is expected to be consistent, as both measures would likely be affected. However, a larger sample could have provided more valuable information, especially regarding the characteristics of self-harm among adolescents.

Information about self-harm is based on self-reports and may thus suffer from report biases. Regarding our definition of self-harm cases, there has been a coding of the responses given in an open question to further verify the validity. However, we did not ask whether the adolescents had a wish to die when they harmed themselves and could not establish whether the intent was suicidal or non-suicidal.

We have also based the criteria for ADHD screening status on self-report data, which could increase the possibility of response biases. Since ASRS v1.1 is based on symptoms from the past 6 months, it is possible that the screening status does not persist over time and may be influenced by the current health and life situation of the participant [ 81 ]. A study investigating students in college found that approximately one-fifth of the participants changed screening status across a time interval of at least one week [ 82 ]. Another study demonstrates a high test-retest reliability of ASRS screening status in individuals without ADHD [ 83 ].

Lastly, the youth@hordaland study was conducted on Norwegian adolescents in 2012, which may limit the generalizability of the results to adolescents worldwide in 2024.

Conclusions

Adolescents who screen positive for ADHD seem to have an increased risk of self-harm. Factors such as biological sex, inattentive and hyperactivity-impulsivity symptoms, symptoms of depression and conduct disorder, as well as familial history of self-harm and suicide attempts, affected the likelihood of reporting previous self-harm. After adjustments for these variables, ADHD screening status remained as a significant predictor of having engaged in self-harm. Female sex and high levels of depressive symptoms strongly correlated with self-harm in ADHD-SC+ adolescents, indicating an increased risk of self-harm in adolescents who report both high levels of symptoms of ADHD and depression.

Since adolescents are especially vulnerable to engaging in self-harming behaviors, a greater understanding of the relationship to ADHD symptoms is important in the development of effective prevention and intervention strategies. Clinicians should assess adolescents who report high levels of symptoms of ADHD for the risk of self-harm, even in the absence of a clinical ADHD diagnosis.

Data availability

The Norwegian Health research legislation and the Norwegian Ethics committees require explicit consent from the participants to transfer health research data outside of Norway. For the Bergen Child study, which constitutes the data for the current analyses, ethics approval was also contingent on storing the research data on secure storage facilities located in our research institution, which prevents us from providing the data as supplementary information or to transfer it to data repositories. Individual requests for data access should be sent to [email protected].

Abbreviations

Attention-deficit / hyperactivity disorder

Screen positives for ADHD

Screen negatives for ADHD

Adult ADHD self-report scale

Berkeley girls with adhd longitudinal study

Child and adolescent self-harm in Europe

Confidence interval

Diagnostic and statistical manual of mental disorders

Hyperactivity / impulsivity

Inattention

Non suicidal self-injury

Socioeconomic status

Participant engaged in deliberate self-harm

Short mood and feelings questionnaire

Youth conduct disorder scale

Allely CS. The association of ADHD symptoms to self-harm behaviours: a systematic PRISMA review. BMC Psychiatry. 2014;14(1):133.

Article   PubMed   PubMed Central   Google Scholar  

Plener PL, Schumacher TS, Munz LM, Groschwitz RC. The longitudinal course of non-suicidal self-injury and deliberate self-harm: a systematic review of the literature. Borderline Personality Disorder Emot Dysregulation. 2015;2(1):2.

Article   Google Scholar  

Cipriano A, Cella S, Cotrufo P. Nonsuicidal self-injury: a systematic review. Front Psychol. 2017;8:1946.

Hysing M, Sivertsen B, Stormark KM, O’Connor RC. Sleep problems and self-harm in adolescence. Br J Psychiatry. 2015;207(4):306–12.

Article   PubMed   Google Scholar  

Sunde HF, Kleppestø TH, Gustavson K, Nordmo M, Reme BA, Torvik FA. The ADHD deficit in school performance across sex and parental education: a prospective sibling-comparison register study of 344,152 Norwegian adolescents. JCPP Adv. 2022;2(1).

Biederman J. Attention-deficit/hyperactivity disorder: a selective overview. Biol Psychiatry. 2005;57(11):1215–20.

Lundervold AJ, Halmøy A, Nordby ES, Haavik J, Meza JI. Current and retrospective childhood ratings of emotional fluctuations in adults with ADHD. Front Psychol. 2020;11:571101.

Hirsch O, Chavanon M, Riechmann E, Christiansen H. Emotional dysregulation is a primary symptom in adult Attention-Deficit/Hyperactivity disorder (ADHD). J Affect Disord. 2018;232:41–7.

Barkley RA. Emotional dysregulation is a core component of ADHD. In: Barkley RA, editor. Attention-deficit hyperactivity disorder: a handbook for diagnosis and treatment. 4th ed. New York (US): The Guilford Press; 2015. p. 81–115.

Doyle AE. Executive functions in attention-deficit/hyperactivity disorder. J Clin Psychiatry. 2006;67:21.

PubMed   Google Scholar  

Loo SK, Humphrey LA, Tapio T, Moilanen IK, McGough JJ, McCracken JT, et al. Executive functioning among Finnish adolescents with attention-deficit/hyperactivity disorder. J Am Acad Child Adolesc Psychiatry. 2007;46(12):1594–604.

Biederman J, Newcorn J, Sprich S. Comorbidity of attention deficit hyperactivity disorder with conduct, depressive, anxiety, and other disorders. Am J Psychiatry. 1991;148(5):564–77.

Article   CAS   PubMed   Google Scholar  

Owens J, Jackson H. Attention-deficit/hyperactivity disorder severity, diagnosis, & later academic achievement in a national sample. Soc Sci Res. 2017;61:251–65.

Agarwal R, Goldenberg M, Perry R, IsHak WW. The quality of life of adults with attention deficit hyperactivity disorder: a systematic review. Innovations Clin Neurosci. 2012;9(5–6):10.

Google Scholar  

Danckaerts M, Sonuga-Barke EJ, Banaschewski T, Buitelaar J, Döpfner M, Hollis C, et al. The quality of life of children with attention deficit/hyperactivity disorder: a systematic review. Eur Child Adolesc Psychiatry. 2010;19:83–105.

Nijmeijer JS, Minderaa RB, Buitelaar JK, Mulligan A, Hartman CA, Hoekstra PJ. Attention-deficit/hyperactivity disorder and social dysfunctioning. Clin Psychol Rev. 2008;28(4):692–708.

Nixon E. The social competence of children with attention deficit hyperactivity disorder: a review of the literature. Child Psychol Psychiatry Rev. 2001;6(4):172–80.

Brunkhorst-Kanaan N, Libutzki B, Reif A, Larsson H, McNeill RV, Kittel-Schneider S. ADHD and accidents over the life span–A systematic review. Neurosci Biobehavioral Reviews. 2021;125:582–91.

Nock MK. The Oxford handbook of suicide and self-injury. Cary (US): Oxford University Press, Incorporated; 2014.

Book   Google Scholar  

Muehlenkamp JJ, Claes L, Havertape L, Plener PL. International prevalence of adolescent non-suicidal self-injury and deliberate self-harm. Child Adolesc Psychiatry Mental Health. 2012;6(1):10.

Tørmoen AJ, Myhre M, Walby FA, Grøholt B, Rossow I. Change in prevalence of self-harm from 2002 to 2018 among Norwegian adolescents. Eur J Pub Health. 2020;30(4):688–92.

Impey M, Heun R. Completed suicide, ideation and attempt in attention deficit hyperactivity disorder. Acta Psychiatrica Scandinavica. 2012;125(2):93–102.

Septier M, Stordeur C, Zhang J, Delorme R, Cortese S. Association between suicidal spectrum behaviors and Attention-Deficit/Hyperactivity disorder: a systematic review and meta-analysis. Neurosci Biobehavioral Reviews. 2019;103:109–18.

Giupponi G, Giordano G, Maniscalco I, Erbuto D, Berardelli I, Conca A, et al. Suicide risk in attention-deficit/hyperactivity disorder. Psychiatria Danubina. 2018;30(1):2–10.

Balazs J, Kereszteny A. Attention-deficit/hyperactivity disorder and suicide: a systematic review. World J Psychiatry. 2017;7(1):44.

Garas P, Balazs J. Long-term suicide risk of children and adolescents with attention deficit and hyperactivity disorder—a systematic review. Front Psychiatry. 2020;11:1404.

Hurtig T, Taanila A, Moilanen I, Nordström T, Ebeling H. Suicidal and self-harm behaviour associated with adolescent attention deficit hyperactivity disorder—A study in the Northern Finland Birth Cohort 1986. Nord J Psychiatry. 2012;66(5):320–8.

Barbaresi WJ, Colligan RC, Weaver AL, Voigt RG, Killian JM, Katusic SK. Mortality, ADHD, and psychosocial adversity in adults with childhood ADHD: a prospective study. Pediatrics. 2013;131(4):637–44.

Huang K-L, Wei H-T, Hsu J-W, Bai Y-M, Su T-P, Li C-T, et al. Risk of suicide attempts in adolescents and young adults with attention-deficit hyperactivity disorder: a nationwide longitudinal study. Br J Psychiatry. 2018;212(4):234–8.

Mulraney M, Zendarski N, Coghill D. Suicidality and self-harm in adolescents with Attention-Deficit/Hyperactivity disorder and subsyndromal ADHD. J Am Acad Child Adolesc Psychiatry. 2021;60(9):1049–e513.

Oh Y, Park H, Kim S, Kim HS, Joung Y-S, Hong KS, et al. Psychopathologic profiles and clusters in Tertiary Clinic referred patients with adult attention deficit hyperactivity disorder: a person-centered analysis. Psychiatry Invest. 2021;18(4):304–11.

Meza JI, Owens EB, Hinshaw SP. Childhood predictors and moderators of lifetime risk of self-harm in girls with and without attention-deficit/hyperactivity disorder. Dev Psychopathol. 2021;33(4):1351–67.

Hinshaw SP, Owens EB, Zalecki C, Huggins SP, Montenegro-Nevado AJ, Schrodek E, et al. Prospective follow-up of girls with attention-deficit/hyperactivity disorder into early adulthood: continuing impairment includes elevated risk for suicide attempts and self-injury. J Consult Clin Psychol. 2012;80(6):1041.

Swanson EN, Owens EB, Hinshaw SP. Pathways to self-harmful behaviors in young women with and without ADHD: a longitudinal examination of mediating factors. J Child Psychol Psychiatry. 2014;55(5):505–15.

Murphy KR, Barkley RA, Bush T. Young adults with attention deficit hyperactivity disorder: subtype differences in comorbidity, educational, and clinical history. J Nerv Ment Dis. 2002;190(3):147–57.

Babinski DE, Neely KA, Ba DM, Liu G. Depression and suicidal behavior in young adult men and women with ADHD: evidence from claims data. J Clin Psychiatry. 2020;81(6):22578.

Fitzgerald C, Dalsgaard S, Nordentoft M, Erlangsen A. Suicidal behaviour among persons with attention-deficit hyperactivity disorder. Br J Psychiatry. 2019;215(4):615–20.

Ottosen C, Larsen JT, Faraone SV, Chen Q, Hartman C, Larsson H, et al. Sex differences in comorbidity patterns of Attention-Deficit/Hyperactivity disorder. J Am Acad Child Adolesc Psychiatry. 2019;58(4):412–e223.

Ljung T, Chen Q, Lichtenstein P, Larsson H. Common etiological factors of Attention-Deficit/Hyperactivity disorder and suicidal behavior. JAMA Psychiatry. 2014;71(8):958.

Fuller-Thomson E, Rivière RN, Carrique L, Agbeyaka S. The Dark side of ADHD: factors Associated with suicide attempts among those with ADHD in a National Representative Canadian Sample. Archives Suicide Res. 2020:1–19.

Sun S, Kuja-Halkola R, Faraone SV, D’Onofrio BM, Dalsgaard S, Chang Z, et al. Association of psychiatric comorbidity with the risk of premature death among children and adults with attention-deficit/hyperactivity disorder. JAMA Psychiatry. 2019;76(11):1141–9.

Olsson P, Wiktorsson S, Strömsten LMJ, Salander Renberg E, Runeson B, Waern M. Attention deficit hyperactivity disorder in adults who present with self-harm: a comparative 6-month follow-up study. BMC Psychiatry. 2022;22(1).

Gordon CT, Hinshaw SP. Parenting stress as a Mediator between Childhood ADHD and early adult female outcomes. J Clin Child Adolesc Psychol. 2017;46(4):588–99.

Austgulen A, Skram NKG, Haavik J, Lundervold AJ. Risk factors of suicidal spectrum behaviors in adults and adolescents with attention-deficit / hyperactivity disorder – a systematic review. BMC Psychiatry. 2023;23(1):612.

Balázs J, Győri D, Horváth LO, Mészáros G, Szentiványi D. Attention-deficit hyperactivity disorder and nonsuicidal self-injury in a clinical sample of adolescents: the role of comorbidities and gender. BMC Psychiatry. 2018;18(1).

Ward JH, Curran S. Self-harm as the first presentation of attention deficit hyperactivity disorder in adolescents. Child Adolesc Mental Health. 2021;26(4):303–9.

Brierley NJ, McDonnell CG, Parks KM, Schulz SE, Dalal TC, Kelley E, et al. Factor structure of repetitive behaviors across autism spectrum disorder and attention-deficit/hyperactivity disorder. J Autism Dev Disord. 2021;51:3391–400.

Ojala O, Kuja-Halkola R, Bjureberg J, Ohlis A, Cederlöf M, Norén Selinus E et al. Associations of impulsivity, hyperactivity, and inattention with nonsuicidal self-injury and suicidal behavior: longitudinal cohort study following children at risk for neurodevelopmental disorders into mid-adolescence. BMC Psychiatry. 2022;22(1).

Gerrard LD. Attention deficit hyperactivity disorder symptoms and nonsuicidal self-injury among clinically-referred children and youth [Master’s thesis]. Ontario (Canada): University of Toronto; 2018.

Yoshimasu K, Barbaresi WJ, Colligan RC, Voigt RG, Killian JM, Weaver AL, et al. Psychiatric Comorbidities Modify the Association between Childhood ADHD and risk for suicidality: a Population-based longitudinal study. J Atten Disord. 2019;23(8):777–86.

Lundervold AJ, Hinshaw SP, Sørensen L, Posserud M-B. Co-occurring symptoms of attention deficit hyperactivity disorder (ADHD) in a population-based sample of adolescents screened for depression. BMC Psychol [Internet]. 2016;16(1).

Beauchaine TP, Hinshaw SP, Pang KL. Comorbidity of attention-deficit/hyperactivity disorder and early‐onset conduct disorder: Biological, environmental, and developmental mechanisms. Clin Psychol Sci Pract. 2010;17(4):327.

Hirvikoski T, Boman M, Chen Q, D’Onofrio BM, Mittendorfer-Rutz E, Lichtenstein P, et al. Individual risk and familial liability for suicide attempt and suicide in autism: a population-based study. Psychol Med. 2020;50(9):1463–74.

James A, Lai F, Dahl C. Attention deficit hyperactivity disorder and suicide: a review of possible associations. Acta Psychiatrica Scandinavica. 2004;110(6):408–15.

Kessler RC, Adler L, Ames M, Demler O, Faraone S, Hiripi E, et al. The World Health Organization adult ADHD self-report scale (ASRS): a short screening scale for use in the general population. Psychol Med. 2005;35(2):245–56.

Green JG, DeYoung G, Wogan ME, Wolf EJ, Lane KL, Adler LA. Evidence for the reliability and preliminary validity of the adult ADHD self-report scale v1. 1 (ASRS v1. 1) screener in an adolescent community sample. Int J Methods Psychiatr Res. 2019;28(1):e1751.

Adler LA, Shaw DM, Spencer TJ, Newcorn JH, Hammerness P, Sitt DJ, et al. Preliminary examination of the reliability and concurrent validity of the attention-deficit/hyperactivity disorder self-report scale v1. 1 symptom checklist to rate symptoms of attention-deficit/hyperactivity disorder in adolescents. J Child Adolesc Psychopharmacol. 2012;22(3):238–44.

Adler LA, Spencer T, Faraone SV, Kessler RC, Howes MJ, Biederman J, et al. Validity of pilot adult ADHD self-report scale (ASRS) to rate adult ADHD symptoms. Ann Clin Psychiatry. 2006;18(3):145–8.

Kessler RC, Adler LA, Gruber MJ, Sarawate CA, Spencer T, Van Brunt DL. Validity of the World Health Organization adult ADHD self-report scale (ASRS) screener in a representative sample of health plan members. Int J Methods Psychiatr Res. 2007;16(2):52–65.

Angold A, Costello EJ, Messer SC, Pickles A. Development of a short questionnaire for use in epidemiological studies of depression in children and adolescents. Int J Methods Psychiatr Res. 1995.

Turner N, Joinson C, Peters TJ, Wiles N, Lewis G. Validity of the short Mood and feelings Questionnaire in late adolescence. Psychol Assess. 2014;26(3):752.

Messer SC, Angold A, Costello EJ, Loeber R, Van Kammen W, Stouthamer-Loeber M. Development of a short questionnaire for use in epidemiological studies of depression in children and adolescents: factor composition and structure across development. Int J Methods Psychiatr Res. 1995;5:251–62.

Sharp C, Goodyer IM, Croudace TJ. The short Mood and feelings Questionnaire (SMFQ): a unidimensional item response theory and Categorical Data Factor Analysis of self-report ratings from a community sample of 7-through 11-Year-old children. J Abnorm Child Psychol. 2006;34(3):365–77.

Cheng P-X, Cao F-L, Su L-Y. Reliability and validity of the short Mood and feelings Questionnaire in Chinese adolescents. Chin Mental Health J. 2009.

Lundervold A, Breivik K, Posserud M-B, Stormark KM, Hysing M. Symptoms of depression as reported by norwegian adolescents on the short mood and feelings questionnaire. Front Psychol. 2013;4.

Thabrew H, Stasiak K, Bavin LM, Frampton C, Merry S. Validation of the Mood and feelings Questionnaire (MFQ) and Short Mood and feelings Questionnaire (SMFQ) in New Zealand help-seeking adolescents. Int J Methods Psychiatr Res. 2018;27(3):e1610.

Eyre O, Jones RB, Agha SS, Wootton RE, Thapar AK, Stergiakouli E, et al. Validation of the short Mood and feelings Questionnaire in young adulthood. J Affect Disord. 2021;294:883–8.

Larsson B, Ingul J, Jozefiak T, Leikanger E, Sund AM. Prevalence, stability, 1-year incidence and predictors of depressive symptoms among Norwegian adolescents in the general population as measured by the short Mood and feelings Questionnaire. Nord J Psychiatry. 2016;70(4):290–6.

Patton GC, Olsson C, Bond L, Toumbourou JW, Carlin JB, Hemphill SA, et al. Predicting Female Depression Across Puberty: a two-nation longitudinal study. J Am Acad Child Adolesc Psychiatry. 2008;47(12):1424–32.

McKenzie DP, Toumbourou JW, Forbes AB, Mackinnon AJ, McMorris BJ, Catalano RF, et al. Predicting future depression in adolescents using the short Mood and feelings Questionnaire: a two-nation study. J Affect Disord. 2011;134(1–3):151–9.

Lucas CP, Zhang H, Fisher PW, Shaffer D, Regier DA, Narrow WE, et al. The DISC predictive scales (DPS): efficiently screening for diagnoses. J Am Acad Child Adolesc Psychiatry. 2001;40(4):443–9.

Madge N, Hewitt A, Hawton K, Wilde EJD, Corcoran P, Fekete S, et al. Deliberate self-harm within an international community sample of young people: comparative findings from the child & adolescent self-harm in Europe (CASE) study. J Child Psychol Psychiatry. 2008;49(6):667–77.

R Core Team. R: a Language and Environment for Statistical Computing. Vienna, Austria: R Foundation for Statistical Computing; 2022.

Ewen Harrison TD, Riinu Ots. finalfit: Quickly Create Elegant Regression Results Tables and Plots when Modelling2023. https://CRAN.R-project.org/package=finalfit

Xie Y, knitr. A Comprehensive Tool for reproducible Computational Research. Chapman and Hall/CRC; 2014.

Xie Y. Dynamic documents with {R} and knitr. 2nd ed. Boca Raton, Florida: Chapman and Hall/CRC; 2015.

Xie Y, knitr. A General-Purpose Package for Dynamic Report Generation in R2022. https://yihui.org/knitr/

Nock MK, Joiner TE Jr, Gordon KH, Lloyd-Richardson E, Prinstein MJ. Non-suicidal self-injury among adolescents: diagnostic correlates and relation to suicide attempts. Psychiatry Res. 2006;144(1):65–72.

Lockwood J, Townsend E, Daley D, Sayal K. Impulsivity as a predictor of self-harm onset and maintenance in young adolescents: a longitudinal prospective study. J Affect Disord. 2020;274:583–92.

Stormark KM, Heiervang E, Heimann M, Lundervold A, Gillberg C. Predicting nonresponse bias from teacher ratings of mental health problems in primary school children. J Abnorm Child Psychol. 2008;36(3):411–9.

Brevik EJ, Lundervold AJ, Haavik J, Posserud MB. Validity and accuracy of the adult Attention-Deficit/Hyperactivity disorder (ADHD) self‐report scale (ASRS) and the Wender Utah rating scale (WURS) symptom checklists in discriminating between adults with and without ADHD. Brain Behav. 2020;10(6):e01605.

Lovett BJ, Ferrier DE, Wang T, Jordan AH, Adult ADHD. Self-report scale screener ratings in College students: concurrent validity and test–retest reliability. J Psychoeducational Assess. 2021;39(8):1015–9.

Silverstein MJ, Alperin S, Faraone SV, Kessler RC, Adler LA. Test–retest reliability of the adult ADHD self-report scale (ASRS) v1.1 screener in non-ADHD controls from a primary care physician practice. Fam Pract. 2017;35(3):336–41.

Download references

Acknowledgements

The authors are grateful to all participants who made this study possible and would also like to thank the Bergen Child Study group.

The youth@hordaland study is funded by yearly assets provided by the Norwegian Health Ministry (Helse- og Omsorgsdepartementet) to the Regional Centre for Child and Youth Mental Health and Child Welfare, Bergen, Norway. This study has additional funding from Stiftelsen K.G. Jebsen Center (SKGJ MED-02) and the Norwegian ADHD Research Network (NevSom) at the University of Bergen.

Open access funding provided by University of Bergen.

Author information

Authors and affiliations.

Department of Biomedicine, Faculty of Medicine, University of Bergen, Bergen, Norway

Amalie Austgulen & Jan Haavik

Department of Child and Adolescent Psychiatry, Division of Psychiatry, Haukeland University Hospital, Bergen, Norway

Maj-Britt Posserud

Department of Clinical Medicine, Faculty of Medicine and Dentistry, University of Bergen, Bergen, Norway

Department of Psychosocial Science, Faculty of Psychology, University of Bergen, Bergen, Norway

Mari Hysing

Regional Centre for Child and Youth Mental Health and Child Welfare, NORCE Norwegian Research Centre, Bergen, Norway

Division of Psychiatry, Haukeland University Hospital, Bergen, Norway

Department of Biological and Medical Psychology, University of Bergen, Bergen, Norway

Astri J. Lundervold

You can also search for this author in PubMed   Google Scholar

Contributions

AA: Design and conceptualization, statistical analysis, writing original draft.MP: Data curation, design and conceptualization, review and editing.MH: Data curation, project administration, review and editing.JH: Conceptualization, review and editing, supervision.AJL: Data curation, conceptualization, review and editing, supervision.

Corresponding author

Correspondence to Amalie Austgulen .

Ethics declarations

Ethics approval and consent to participate.

The study was approved by the Regional Committee for Medical and Health Research Ethics (REK) in Western Norway. Informed consent was obtained from all participants included in the study. In accordance with the regulations from the Regional Committee for Medical and Health Research Ethics in Western Norway (REC) and Norwegian health authorities, adolescents aged 16 years and older can make decisions regarding their own health (including participations in health studies), and thus gave consent themselves to participate in the current study.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Additional information

Publisher’s note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary Material 1

Rights and permissions.

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

Austgulen, A., Posserud, MB., Hysing, M. et al. Deliberate self-harm in adolescents screening positive for attention-deficit / hyperactivity disorder: a population-based study. BMC Psychiatry 24 , 564 (2024). https://doi.org/10.1186/s12888-024-06008-3

Download citation

Received : 03 December 2023

Accepted : 08 August 2024

Published : 19 August 2024

DOI : https://doi.org/10.1186/s12888-024-06008-3

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Adolescence
• Attention deficit hyperactivity disorder
• Deliberate self-harm
• Self-injury

BMC Psychiatry

ISSN: 1471-244X

• Submission enquiries: [email protected]
• General enquiries: [email protected]