Professor Dennis Ougrin Wonderful. Welcome back.   We have our final speaker for the  conference, Professor Paul Plener,   who’s Head of the Department of Child Psychiatry  at Vienna General Hospital and Chair of Child and   Adolescent Psychiatry at the Medical University  of Vienna, as well. And he is also President-Elect   of the Austrian Association of Child and  Adolescent Psychiatry, which I didn’t know,   and congratulations, Paul, on that. Professor  Plener’s research interest is focused on NSSI,   suicide and trauma, and I asked him about the  fun fact – I know so many fun facts about Paul,   but I asked him what he would like to highlight  and – which I – well, he told me something new,   which I didn’t know about, which is that he’s  co-hosting a national radio programme in Austria   on pop music and mental health. That’s an  extraordinary thing and linked to David’s   fun fact about Glastonbury Festival.  So – but that’s over to you, Paul. Professor Paul Plener Well, thank you, Dennis,  for having me here and yeah, I would like to focus   on the therapeutic approaches for challenging  behaviours for self-harm, and we’ve heard a   lot of that within the last two days. And it  gives me the opportunity to, more or less,   go over some details briefly, but trying to get  an angle on meta-analysis and systematic reviews.   Tom, how can I click to the next one?   Okay, next slide. I thought this clicked remotely  with somewhere. Well, these are my research   fundings, which – regarding this talk. Provide  no conflict of interest. Next slide, please. You can’t talk about anything in mental  health these days without mentioning the   COVID-19 pandemic, so I’d like to point  out that, also, with respect to numbers   of self-harm and presentations to the Psychiatric  Emergency Department, there has been an increase,   comparing 2019 to 2020 and also comparing  2019 to 2021, showing that rates of self-harm   presentations have increased. This is a paper  that Dennis’s group co-ordinated with a high   number of Psychiatric Emergency Departments from  all around the world. And there seems to be a   higher proportion of self-harm presentations  with regards to Psychiatric Emergency Room   or Emergency Department presentations  in child and adolescent psychiatry. So,   it seems that COVID-19 has led to an increase  in self-harm presentations, so I think it’s a   very relevant topic to tal – that we’re talking  about in these two days. Next slide, please. And if we want to talk about therapy, I  think we should start from the very question,   why do adolescents hurt themselves? Next slide,  please. And there’s been this rather old four   function model and so, it’s nearly out now  for 20 years, that says that you either use   self-injury or self-harm to try and change  something with regards to your own person,   with regards to your feelings. These have been  called the automatic or interpersonal functions   of self-injury. Or you want to change something  with regards to the interpersonal connections,   your social environment. And there can be both  negative or positive reinforcement going on,   which means that, for example – as an  example for automatic negative reinforcement,   you’re in a bad feeling, you have a – some sort  of aversive emotional state and then, you hurt   yourself and it somehow disappears for a while,  or it gets better. And this is the reason that   is most often cited in literature, so that people  use self-harm in a way to regulate their negative   emotions. And it’s not an either/or question, so  it’s not either automatic or social, but it can   be a couple of reasons that come together when  talking about self-harm. Next slide, please. There’s also been another model that’s been  proposed by Jill Hooley and Joe Franklin from   back in 2018. It’s called the “Benefits and  Barriers Models” and it is developed on the   idea that there are a lot of adolescents  worldwide who are injuring themselves,   so there has to be some benefits. Next slide,   please. And with regard to these benefits –  next slide. Try to push it once more, again.   Well, it somehow relieves them when they’re in  a state of bad mood and it also seems to gratify   desires for self-punishment. It can provide  some sort of peer support affiliation if you’re   in a certain peer group and it can communicate  distress or even strength to the outside world. Well, there are a lot of positive  things, but when talking about barriers,   we do see a majority of adolescents  who are not injuring themselves,   so what might keep them away from self-injury or  self-harm? Can I get next button. Well, it can   be that they simply lack exposure to self-injury,  or they are not aware that such behaviours exist.   Some of us have a desire to avoid physical pain,  and we’ve heard about Michael talking about pain   and how it may modulate the way to suicidality.  So, I think he made a valid point there.   Some people say that they’ve found all  this non-suicidal self-injury stimuli,   like razorblades or blood, very aversive to look  at and they keep away from that thing at all.   There are some group of adolescents  in which self-injury is just not cool,   so it’s somewhat without – it’s not fitting into  their social norms of the group. And as Hooley and   Franklin pointed out, if you have a very positive  view of yourself, it makes little sense hurting   yourself, so this might also be a protective  factor. Can I get the next slide, please? So, thinking about that, there might be some  targets for therapy that we need to dive into,   one being very prominent emotion regulation.  So, it’s about recognising your emotion and   talking about skills and learning skills to alter  your negative states. Another thing being social   skills, communicating distress, asking for help,  and getting better at social problem solving,   because we heard a lot about those interpersonal  stressors from Michael. So, people getting better   at solving their social problems might  – are better fitted to tackle self-harm   urges. And then, it’s about  interpersonal coping. Of course,   if there’s some story of post-traumatic stress  disorder or aversive childhood experiences,   then it could be a target for therapy, as well.  Also, some automatic beliefs, or some core pain,   as it’s called in therapeutic assessment, and  self-hatred that can be tackled through therapy   and, of course, family issues. As you’ve seen,  there seems to be some issues regarding your   parents that can be a main stressor when  it comes to self-harm. Next slide, please. So, that’s the first summary on  how we can help adolescents who   self-harm. It’s mostly about “hugs  not drugs” when trying to sum up   the evidence that we have on different  treatments for self-harm. Next slide, please. You’ve heard in detail some of the things  that I’m going to show you now, because   you’ve listened to Michele Berg yesterday and  you’ve listened to Michael Kaess today and some   of the graphs that I’m showing you here, you’ve  already seen in the talks in the last two days.   The only thing I wanted to point out here is  that, as you’ve heard, DBT-A has a potential   to reduce self-harm and the same is true for  CBT. Although we have to acknowledge that   with respect to controlled  conditions, like enhanced usual care,   or individualised and group standardised  therapy, or to standard psychotherapy,   like in Michael Kaess’ study of Cutting Down,  might seem that on the long run, people get better   in both treatment conditions. But it has to be  said that the effect size, like, for example, in   the Cutting Down programme, is pretty impressive,  with nearly one for the Cutting Down programme in   declining or decreasing the frequency  of self-harm. Next slide, please. Looking into other modes of therapy, namely into  mentalisation-based therapy for adolescents,   or there’s a new paper out, but this is  only available in German, I’m afraid,   for transference-focused psychotherapy in  adolescents. There has been some hints that it   seem – both of them seem to decrease self-harm or  DMDD, studied by Rossouw and Fonagy showing that   after 12 months, there seems to be a decrease in  comparison to treatments. Usual group, although   it has to be said that there’s this other study  by Griffith showing that if you’re only looking   to the introductory group, you get a decrease in  self-harm, but this decrease can also be found in   the treatment as usual group, as well. So, these  are, as I will mention later on, again, some hints   that treatment as usual seems to work in a way for  reducing self-harm, as well. Next slide, please. And these are some modes of therapy that somehow,  are just being used and the trials are ongoing,   but just to give you some very short introduction  to some pilot trials that have been done with   regards to ERGT or ERITA. So, this is emotion  regulation group therapy by Kim Gratz and   this was done in adult women with BPD, showing  that there’s a decrease in deliberate self-harm   and then, Johan Bjureberg showed that it  also works as an individualised therapy. So,   ERITA stands for emotion regulation individual  therapy for adolescents, in an open trial,   that it decreases self-harm, but of course,  this is just an open trial, and it hasn’t   been randomicon – randomised under controlled  treatment study, so we don’t have a control group. But the fascinating thing that Johan Bjureberg  with – did was actually he take the programme   and do an online version of that. So, this  is another open trial, but it’s working on   11 models for both parents and children and they  just receive written feedback from a Therapist and   he was able to show that there’s a reduction in  non-suicidal self-injury in this online version,   although again, this is not controlled for, where  the treatment is usual condition. This is just to   show you that there are some things happening with  regards to online treatment. Next slide, please. So, there is this rather recent review on brief,  manualised Specific Psychotherapeutic Intervention   with regards to self-harm, and there are numerous  trial and they were looking into what is happening   and what are methods that are not taking a  longer time. So, they have a very short span,   or duration, of treatment that is administered.  And they were looking into developmental group   psychotherapy, finding no significant different  to treatment as usual, therapeutic assessment   with regards to self-harm reduction, no  significant difference to therapeutic – to   treatment as usual, Cutting Down programme, no  significant different to treatment as usual.   Although all of them showed a reduction  in self-harm, and as I showed you, ERITA,   the open trial with no control condition and  there’s the model of – from Bronx – Peggy Andover,   “Treatment in Self-Injurious Behaviors,”  that has been tested in young adults   and there’s been a slight reduction with regards  to self-harm in comparison to treatment as usual.   And then, there’s Intensive Contextual Treatment,  which is also there for an open pilot. So,   there’s a trend that we can see here that  there seems to be a reduction of self-harm,   but this reduction can be found in treatment  as usual groups, as well. Next slide, please. So, there’s another therapeutic – systematic  review on the therapy of self-harm and suicide   attempts, enclosing 21 studies, and  there has been the finding that both   CBT and DBT-A should replicate that effects  on self-harm and suicide attempts and there’s   a benefit of combination of self-driven and  systems-driven approaches. Next slide, please. So, what I find very meaningful about the  systematic review, that they argued that   there are some things that successful programmes  have in common, and it seems to be the involvement   of a family member, or a significant support  person, seems to be that within the programmes,   emotion regulation skills are trained.  The same is true for problem solving   skills and there is an – also an emphasis  on communication skills. Next slide, please. There’s this systematic review around  self-injurious thoughts and behaviours,   that included 26 RCTs and this was, kind  of, an update from an older systematic   review by Kathy Klein, and she said that  there’s, at the moment, one level one   therapy programme, which is DBT-A, which can  be – as Michele Berk pointed out yesterday,   is now a well-established intervention. And then,  there’s MBT-A and CBT, which are on level two,   for example, and Kathy also talked about, in the  paper, about elements of efficacious interventions   and she is – also pointed out that they need to be  family centred, so there should be a significant   family or parent training component. There needs  to be skilled training and she also looked into   treatment dosing and said that there seems to be  a minimum of six weeks for self-injury and three   to 12 months for suicide attempts, so that  it might be efficacious. Next slide, please. I also looked into the recent literature on youth  and adults and systematic reviews with regards to   borderline personality disorder, where we often  find self-harm is a secondary outcome measure.   And this was in the latest review on adolescents  pointed out in six studies on BPD adolescents by   Jorgensen, and he’s pointed out that with regards  to MBT, there was no effect, with regards to DBT-A   there was a decrease in self-harm and with regards  to cognitive analytic therapy, also no effect in   comparison to treatment as usual group. Whereas,  in adults, there was an effect for MBT and for DBT   or DBT-A, with other treatment interventions  showing no effect. Next slide, please. There’s also this Cochrane review on self-harm  in minors, including 17 trials, coming up with,   again, DBT-A showing a lower rate of  self-harm repetition, and they said that   individual CBT might be helpful. So, there  may be evidence of repetition of self-harm,   and with regards to MBT-A, they  stressed that it’s uncertain whether   this leads to reduction of self-harm.  So, they say it, but as a conclusion,   DBT-A warrants further evaluation and the same  is true for individual CBT. Next slide, please.  So, we were doing another meta-analysis  on self-harm and suicidal ideation,   including 25 RCTs and this is the point  that I wanted to make from the very start,   that we did found a small effect size, that  was significant, that psychotherapeutic,   or some psychotherapeutic interventions, have the  potential to reduce self-harm in comparison to   the treatment as usual condition, and this was  DBT-A, MBT-A and CBT. But we also found large   effect sizes for the decrease of self-harm in the  treatment as usual conditions, them being, like,   .6. When comparing different methods of treatment,  DBT-A showed the largest effect sizes with regards   to repetition of self-harm in comparison to  treatment as usual, with .51. Next slide, please. So, it might make sense to think about treatment  as usual, and I really liked the talk of David   Cottrell before, because I think he has a  point in say that Clinicians are aware of   evidence-based practice and are probably doing  the right thing. So, I think it makes sense,   as not everybody is trained in DBT to think  about things that you can do right in treatment   as usual. And some of these things we’ve  stated in the German treatment guidelines,   so that there should be clear contracts and  therefore, suicidality or NSSIs and what happens   after these acts happen. Some building commitment  for treatment, as well as psychoeducation at the   start of treatment and then, it’s about  identifying factors to trigger or maintain   non-suicidal self-injury, providing alternative  behavioural skills or problem-solving strategies,   but also attention to and treatment of comorbid  psychiatric disorders. Next slide, please. And I came upon this paper, which for me, is so  far, the best paper I’ve read in 2023. It’s a   Practitioner’s review in the JCCP and they were  looking into common elements that treatments   for suicide attempts and self-harm use, and  Dennis Ougrin, a co-author on this paper,   as well. I really enjoyed reading it, because  they tried to get to the core elements of   what supported trials are doing right, or which  supported trials, and supported with regards to   reducing self-harm, which are the common elements  that they’re using? And with regards to the   format, you find that there’s the involvement of a  family caregiver, there’s 24/7 phone coaching for   crisis. We’ve got to the process, it’s about  eliciting and addressing patient concerns,   it’s about monitoring self-harm throughout  treatment, it’s trying to put an emphasis   on therapeutic alliance and the relationship  building. It should be individualised case   conceptualisation and a commitment to safety  process. Next slide, please. Next slide. So, yeah, and with regards to the  content, it’s about you should use   some safety planning, you should talk about  social/interpersonal skills, teach mindfulness,   keep in mind that you’re counselling for  safety and also address impulse control.   So, there are some points that you  can do right, I guess, in treatment   as usual and this would involve – include the  caregivers, provide skills on different levels,   work on the therapeutic alignments –  alliance and put some emphasis on safety,   biosafety planning, safety monitoring,  also. Next slide, please. Next. So, we now know that something seems to help.  Next. But there are barriers to treatment.   Next. There’s the issue of scalability  and the availability of treatment. Next,   and there’s a low motivation for psychotherapy  in some of the kids. Next slide. So, I think   with regards to barriers, and Michael touched  on that point, that between a third and half   of adolescents with NSSI don’t seek any help and  primarily turn to friends and families, because   some of them feel it’s too unimportant for real  therapy. Some of them feel that they, kind of,   started it, so that they should need to cope with  it for themselves. There’s the stigma of attention   seekers and there’s also some concerns about when  you’re turning to therapy, would involve their   parents when they don’t want to share their  self-injury with them. Next slide, please. So, of course, you’re pretty much aware  of therapeutic assessment as a way of   increasing motivation for further therapy.  This has been shown by Dennis in an RCT,   so that they turn up in therapy more  often after the therapeutic assessment   and they visit more sessions. So,  there’s – we have something where   we can increase motivation and we know  how it can be done. Next slide, please. And, also, with regards to scalability, I think  we need to turn more with – to digital inventions.   There’s been this trial by Jill Hooley, this RCT,  where she tried to compare different ways to,   kind of, use an online daily diary with regards  to self-injury and what happened throughout   the day. And the fascinating thing was that  regardless of in which condition they were,   as soon as they started writing up  what happened to them on a daily basis,   self-injury declined, as you can  see in the graph here, but then,   after stopping the daily journaling,  it went up to the level as before. So, daily journalling in itself, and you  can, of course, use digital versions of that,   seem to have some sort of an effect, and there’s  also this very interesting app by Joe Franklin,   the Therapeutic Evaluative Conditioning app, and  he has provided three different RCTs on the app,   that works on classic conditioning,  stimuli of NSSI with aversive stimuli,   and as long as adolescents are using that app,  their self-harm frequency decreases. So, that   could be – of course, this is not something that  could be used instead of therapy, but it can be   used as an adjunct, for example. And it’s freely  available without any cost. Next slide, please. There are some ongoing trials. Michael showed  you some of the preliminary results from the   STAR trial and since we’re together in  one big consortium, the STAR consortium,   I can say that probably data collection  will be finished this year, because he’s   very ahead of the schedule. So, I think you’ll  probably hear some of the results, maybe, yeah,   maybe this time next year, and there’s also  an RCT running for ERITA, which I showed you.   So, Johan Bjureberg is – there’s also  the trials – a paper out there that will   see some of the digitalised interventions  coming further, soon. Next slide, please. So, within the last couple of minutes I  wanted to go to a road we’re less travelled,   next slide, please, and I wanted to talk  about things that don’t need talking.   Next slide, please. One of them being  psychopharmacology and this is, kind of,   a rather depressing story, as you can hear, in  the Cochrane review. Next slide, please. You   don’t have to see that in detail, but there’s a  couple of different psychopharmacological agents   that are discussed and it’s the same wording  for every agent. There’s no evidence available   to support that it helps in decreasing  the frequency of self-harm. Next slide. There’s been this recent systematic review  and meta-analysis of studies that have been   conducted with regards to reduction  of NSSI in adolescents, and there were   enough papers to show that SSRIs don’t have  any benefit in reducing NSSI and there were   not enough papers to really calculate the  effect, but only anecdotal evidence from   different studies that benzodiazepines seem  to increase self-harm, the same is true for   trazodone at a – used as an add-on. There’s been  an increase in retrospective FDA analysis for MPH,   so methylphenidate increasing the rate of  self-harm and from a retrospective chart review,   there’s been a decrease when using ziprasidone,  but this is very low level of evidence. These   are just anecdotal reports from one  or two studies. Next slide, please. Then there’s been this case series by  Katie Cullen, of 35 adolescents receiving   N-acetylcysteine. In this open-label  study there was a reduction of NSSI,   but following up on this in trials register, I  found that there was a registered trial for an   RCT for N-acetylcysteine, but this was abandoned  after seven subjects were into the study because   there was also some issues with an increase of  self-harm. So, that’s the last thing that we’ve   heard about this component, which proved to be  effective in trichotillomanini – trichotillomania.   So, there was the idea where it came from,  so – and there’s also been an RCT on that,   which proved to be effective, but still, we’re  not there yet in NSSI. Next slide, please. There was a question regarding sleep  and NSSI and I wanted to point out that,   as Michael also said, that there’s an  increasing evidence that sleep problem   seemed to correlate with both suicide attempts,  but also with NSSI and there’s a study that’s   showing that sleep problems predict NSSI by  30 days. There’s also a ten-day actigraphy   and EMA study on sleep, showing that those with  NSSI, there was not the correlation with sleep   total time and bedtime with NSSI, but there  was a greater variance in sleep patterns and   there was a higher rate of irregularity in  adolescents with NSSI. Next slide, please. And there was – has also been this longitudinal  study following up them – for adolescents for five   years, showing there’s a relationship between  NSSI and insomnia, but there was also a clear   influence of depressive symptoms, which of course,  also influences sleep pattern. Next slide, please. And another thing that I wanted to point out,  that there seems to be some relationship to   physical exercise and there’s been this great  study that’s been – like, a single case study,   with a very nice design. It’s been published  in the American Journal of Psychiatry with   Anna [Wan – 2757], showing that an on/off  of physical exercise can decrease NSSI   and it has been shown from adults from  a partial hospitalisation programme,   that past week physical activity, if there’s a  decrease, there’s an increase in NSSI. We found   that in those high school students who identified  themselves as athletes, they had lower rates of   non-suicidal self-injury, and another study  of high schools students showing that NSSI   frequency was negatively related to physical  activity. And, also, there’s – these affected   exercise modulates the direct effect of positive  emotion regulation ability on NSSI, whereas sleep   modulates the direct effect of negative emotion  regulation ability on NSSIs. So, we have the two   components of sleep and physical activity that  we need to keep in mind. Next slide, please. Another thing that is – there’s some new  studies that look into vagal stimulation,   because we know that lower vagal activity  often goes together with a higher arousal   and higher vagal activity, the lower arousal  and – you can find the lower vagotonus in   patients with emotional dysregulation. Also,  a lower heart rate variability in borderline   personality disorder and a higher heart  rate variability when entering treatment,   well, DBT-A treatment, is a predictor for a  better outcome. I also see that heart rate   variability decreases after NSSI or after seeing  blood, so that NSSI might be understood as some   sort of a vagal stimulation, and we can think  about other ways to achieve that. And there   – there’s this meta-analysis showing that  the transcutaneous auricular vagus nerve   stimulations showing no change in vagal mediated  HPV [means HRV], but there’s been some sort of   a better cognitive reappraisal in emotion  regulation tasks in healthy controls. So,   I think that this might be a way that we need  to look into, because it’s non-invasive and it’s   something where we can add things to a therapy  and increase vagotonus. Next slide, please. And of course, you can also think about Repetitive  Transcranial Magnetic Stimulation, because we know   that we can, by cortical stimulation, increase the  activity in the dorsolateral prefrontal cortex,   that we know is, kind of, really, really  interesting with regards to impulsivity. There has   been single case studies in BPD with – was shown  that there’s a decrease in impulsivity and better   emotion controls and there are, in the systematic  review, first, hints showing an efficacy in BPD,   but we don’t have any double-blind placebo  controlled randomised trial. Next slide, please. What we are looking at, at the moment is  transcranial direct current stimulation. There   has been a systematic review in BPD, showing that  there’s enhanced frontolimbic connectivity, but   overall, a rather bad quality of studies. We know  that there’s an effect on heart rate variability   and there’s been a study in adults in RCT, sham  versus transcranial direct current stimulation,   showing that it can have an increased cognitive  reappraisal. So, we are looking, at the moment,   of trying to enhance emotional regulation  by stimulating them. Next slide, please. So, to sum it up, I think we need to  talk about the stepped care approach when   talking about therapy in self-harm. I think  the first step is that we need to get better,   so that adolescents actually overcome the barriers  for seeking treatment and the stigma of work,   providing access to care, gatekeeper training and  also, if there’s any digital interventions that   can be – that is available, a very low threshold,  it can help to overcome those barriers. And the   next step needs to be to increase motivation  for psychotherapy, with therapeutic assessment,   psychoeducation, motivational interviewing,  and then, as has been shown by Michael Kaess,   there are brief manualised dimensions which  seems to increase self-injury and then, there   will still be adolescents who harm themselves and  for them, I think we need – still need to have all   those treatments with higher frequency or higher  intensity, at the back of our hands. And we could   add apps and online resources, an adjunct to all  these therapeutic avenues. Next slide, please. And I think we need to get better in  looking into sleep and how we can help   adolescents to sleep better and also look  into physical exercise. Next slide, please.   So, this is what I would call the ‘listen to your  mom approach’, because we all know that it helps,   but still, it’s not easy working clinically  with adolescents to get them to do this. But   there’s quite some evidence to show that it could  improve self-harm frequency. Next slide, please. And of course, I think we still need to  look into new pharmacological agents,   and I know that there are some trials ongoing  which – with new agents, trying to really focus   on emotion regulation as a primary outcome. And  I think that within the next five to ten years,   because there are studies now out on  adolescents – on adults in Phase II,   which are following a completely new path, I  think that we might see some new components.   And there are – so, might be a potential for  other biological treatments, such as tDCS, rTMS or   transauricular – transcutaneous auricular neural  vagal stimulation. Next slide, please. Next. So, self-harm is a highly prevalent phenomenon in  adolescents and as I’ve told, it does often affect   regulation function that it’s serving, at least,  and we have technology that it works. And if we   want to get adolescents away from self-harm, we  need to do better and try to give them something   that works, as well. Next slide, please. We know  that psychotherapy helps to reduce self-harm,   but treatment as usual does, as well. Next slide,  please. Next slide, please, and we need to get   better at lowering thresholds to therapy,  increase scalability, add new components,   so augmentation strategy, tend to look out for  sleep and physical activity. Next slide, please. So, I think it’s a pretty exciting  time. We need to try out new things,   collect data and share what we’ve been doing,  and this is the point where I’d like to mention   that the next conference for the International  Society for the Study of Self-Injury will be held   this year in Vienna in person. So, for anybody  of you who always wanted to come to Vienna,   I think the 22nd and 23rd of June this year might  be a great opportunity, and you can find further   information on the homepage on the International  Society for the Study of Self-Injury. Next slide. And I’ve finished with my talks. Thank you all  for listening, and I’m open to any question,   thank you very much. Professor Dennis Ougrin   Oh, thank you, Paul. It was wonderful to have  this really wonderful overview and also looking   ahead a little bit, as well, it’s something  that I really enjoyed and learned a lot from.   So, let’s look at the questions. We  have a question from Andrea Tocca,   “How much weight has boredom and sense of  emptiness,” I guess, “has in self-harm?” Professor Paul Plener A sense of emptiness comes  up as one of the five major reasons when looking   into functions of self-injury. There’s been this  brilliant meta-analysis from Taylor in 2018,   looking into functions and motives for NSSI  and sense of emptiness and also maybe can be   linked to, like, a feeling of not feeling  anything, is one of the top five reasons   that have been mentioned. So, I – and yes,  that’s providing some sort of sensation,   although it might be painful, seemed to be a  motivator for some of the adolescents, yeah. Professor Dennis Ougrin Then,  a question from Sophie Bench,   “Are there any proven alternatives to NSSI  that have an affective regulatory function?” Professor Paul Plener Well, we do know that  affect regulation gets better after DBT-A,   also on the brain level. So, I would say yes,  we know that from many studies looking into   affective regulation, so DBT-A, in itself, works  for getting better at affective regulation. And,   of course, there is also some – a lot of different  skills that people use for affect regulation and   it seems that skills, as I’ve mentioned before,  is one of the core elements that you can do right   in getting better at affect regulation.  And – but also, mindfulness plays a role,   because you might not progress to a level where  you need severe acts to regulate yourself,   but you can also, you know, get a feeling on  – you know, I might feel a bit distressed and   react on it now, instead of, you know,  keeping everything under con – trying to   keep everything under control and get to  a much higher level of stress afterwards.   So, I would say yes, there are some proven  elements that work on affect regulation. Professor Dennis Ougrin Wonderful. Another  question from Andrea, “Would you say that   structural clinical management is the best  approach as value for money and efficacy goes?” Professor Paul Plener I really like the  approach like Gunderson with regards to   borderline personality disorder, talked  about the good psychiatric management,   and something that you can do right. And I  think that with regards to cost effectiveness,   yes, I would definitely say yes, although it  – there’s not a lot of literature on that,   but I would be very interested to see a  study on – you know, of course, you have to   see how this structured clinical approach looks  like and come up with some core elements that   needs to be checked, to be able to look  into what is actually happening there. But I would – I’m a fan of, saying yeah, probably  that’s the best you can get for your money, yeah,   because you can train – I think you can train  people on the things that they can do right,   maybe within half a day to a day and then, of  course, provide supervision, which I think is key   in treating adolescents. But then, well, still,  there aren’t any studies out on that thing, but I   would say yes about – Gunderson has shown that it  works, and he compared good psychiatric management   with regards to BPD to MBT or the DBT in RCTs and  was able to show that it’s working quite well. Professor Dennis Ougrin And   another question from Peter Hindley, “I have seen  Clinicians using clozapine for young people with   severe NSSI and emerging emotional unstable  personality disorder in inpatient settings.   It appears helpful with some individual.  Is there any published data on its use?” Professor Paul Plener To my knowledge,  it’s two individuals that the literature   is funded upon. So, there’s these two cases  that there’s some papers on clozapine.   I don’t know if anything happened within the  last two years, to be honest, but still, in this   recent systematic review that I showed you,  there was not something popping up with regards   to clozapine. So, I think I’m quite right on  that, still. So, clozapine worked in two cases   and that’s the evidence that we’re building  up when it comes to published literature,   and also, very interestingly, quetiapine,  that is used a lot, has been looked into in   the recent reviews, showing that there’s not any  evidence that supports the use of quetiapine in   BPD. But we’re using it, I guess, as an agent  of sedation and, of course, it seems to, yeah,   no, downgrade one of the – or it seems to numb  people, in a way, and I think that we need to   be clear about what we’re doing, also, when  we’re discussing medications with patients. Of course, it can be an avenue to follow,   but it’s not working the way that we’re  specifically addressing something with regards to   the mechanisms of NSSI. I think we’re numbing them  and this is – it can be okay in some cases, but we   need to be clear what we’re doing and probably,  for me, clozapine is pretty much the same. Professor Dennis Ougrin  Let’s see. Sheila Das again,   “A question to both. What is your best tip  on keeping up-to-date without getting lost   in all the many publications which we are all  producing?” That’s a wonderful question. Like,   stop publishing this stuff and just publish,  like, important stuff, it’s a very good… Professor Paul Plener Very good  point. So, my answer would be to,   you know, check for systematic reviews  and meta-analysis every six months.   That’s the thing that I could probably take from  the literature, because the literature on NSSI,   since it has been – or it has been integrated in  the DSM-5, which was in 2013, has exploded and   it’s hard to keep up. So, whenever I’m preparing  another talk, just like today, I’m me, myself,   sitting down and trying to get out what’s there  and what has been coming up. Although I know a lot   of work that has been done, or published, still  there’s a lot of new things coming out each month,   so if you want to keep up, I would really say go  for the meta-analysis and systematic reviews every   six months and that should work, because probably,  you’ll have, like, one or two, then, to read. Professor Dennis Ougrin Yeah. So, we only have  three minutes left. I just want to ask you a   question from me, and obviously, you gave  a really wonderful overview of the field,   including some things that are likely to  come in the next five/ten years. Like,   if you had an unlimited research  budget, like they do in Norway,   what would you – like, and if there’s just  one thing that you would want to invest it in,   in researching and developing,  what would that one thing be? Professor Paul Plener With regards to therapy,  I think it would be to take a closer look at   blended therapy, and how we can, you know,  integrate apps, and there was all this talk   about how to use EMA clinically, apps to track  mood, oh, and give a shorter feedback and gather   a shorter feedback from Therapists, with some  elements that we know are working, so just as   you pointed out in your latest paper, in the JCCP.  So, take these core elements, break them down to,   I don’t know, five to ten sessions, so that I  will be able to train Clinicians within a day   and then, do some sort of applying the therapy  approach with some apps and that will be the   study that I would be most interested in with  regards to therapy. With regards to neurobiology,   there would be a lot of other things that I would  be interested in, but with regards to therapy,   I think getting things shorter and integrating  digital ski – digital techniques into them. Professor Dennis Ougrin And biology, one thing. Professor Paul Plener Well, with regards to  biology, I think that the – this question is still   out whether we can predict NSSI at a very young  age, and by young age, I mean, like, children   in preschool age and try to find biological  markers of pain, which is also, of course,   some sort of an ethical issue. And whether we  could find markers within the inflammatory system   and also markers with respect to their,   you know, social and interpersonal relationships  that they are doing at a very young age. And then,   following them up when they get into the age  where bullying may apply – might apply – play   a role and try to seek out what bullying does  on these biological components, like emotion   regulation of the pain or neuroinflammation. That  would be, of course, the million dollars, the… Professor Dennis Ougrin Wonderful. Alright,  look, we are coming to the end of this conference,   so what I’d like to do is to thank  every presenter for both days.   I really enjoyed – I’ve learned a lot and I  hope that people who listened to this learnt,   as well. I wanted to also thank everybody  who was contributing the questions,   wonderful questions. I don’t know if you  noticed, but I had this option of either   showing a question or not showing a question if  it was inappropriate, and I showed all of them,   because they were all appropriate and interesting.  So, thanks for all of the contributions. Thanks for ACAMH for putting together these things  so well. Just now, disclosure – reminder about   feedback poll. If it’s still available, please  spare a few moments to complete it. And with that,   I’d like to wish you a wonderful weekend  and all the best. Hopefully, we will see   you – we’ll see each other soon at some further  ACAMH conferences, if not in Vienna in June.