Comorbidity depression and self-destructive behavior in adolescence: comparative sex analysis of clinical cases

Today, there is a trend of intentional self-harm, suicide and injury among teenagers. Doctors pay attention that among the reasons for this situation are the depressed state of society, cruelty and indifference in the family, maladjustment in the educational institution, low neuropsychological stability of children and young people, inability to constructively solve personal problems, lack of sustainable interests and interesting organized leisure time, impossibility self-expression and self-realization, etc. The comorbid combination of depressive disorders (DD) and self-destructive behavior (SDB) in adolescence is one of the most important and global problems of modern clinical psychiatry. The gender specifics of such an aggravating variant of DD in boys and girls requires additional research. The objective: to analyze the sexual characteristics of DD in a comorbid combination with SDB in youth. Materials and methods. In the pilot study 48 boys and girls aged 15–18 years with DD (according to ICD-10) and manifestations of SDB were examined in outpatient clinic, namely: 11 (22.91%) boys and 37 (77.08%) girls. The patient health questionnaire (PHQ-9) was used in the study. Results. According to the results of the study, patients were diagnosed with different variants of clinical syndromes of DD. The level of severity of DD had no gender characteristics. Such syndromes as hysterical-depressive, depressive-hy-pochondriac, depressive-dysphoric syndrome were found only in girls. At the same time, hysterical-depressive syndrome occurred most often – in 29.2% of all cases in both groups. The results of the study indicate a tendency towards the predominance of bisexual identification among girls (21.6%) compared to 9.1% among boys. Conclusions. It has been proven that in youth DD have 100% comorbidity with SDB. The presented clinical cases demonstrated severe DD in youth, taking into account gender characteristics. The significant predominance of depressive-obsessive and anxiety-depressive syndromes in young men is an important factor in the comorbid development of SDB (suicidal activity) in these patients.

T he problem of affective pathology, in general, depressive disorders (DD) in young youth, is extremely relevant for modern Ukrainian psychiatry.First of all, the need for a thorough study of these problems applies to young men and adolescents as the most important part of our social capital.Because the prevalence of depression increases significantly in adolescence / young adulthood and has negative consequences for mental health in adulthood.
According to modern research, the combination of DD with other comorbid (behavioral) disorders has the highest risk of adverse outcomes in the age at 24 years [1].For example, the onset of somatoform disorders with various «bodily complaints» in adolescence is directly related to the development of anxiety and depressive symptoms in young adulthood [2].Self-destructive behavior (SdB) and suicidal behavior as part of it is the main comorbid, cumulative, or secondary behavioral pathological characteristic of adolescence with DD [3].Thus suicide is one of the most common causes of death among adolescents, and suicidal thoughts, self-harm increase risk of mental disorders and suicide in the future [4].Also eating disorders are comorbid disturbances with depression in adolescents as equivalent to SdB [5,6].
In the scientific literature, correlation sex with DD is one of important topic of research.For example, the prevalence of depression among women is widespread and clearly visible.A higher level of depression in women is determined by factors such as increased neuroticism, stress reactivity, or hyperactivity of the limbic system, that is based on the stress diathesis model [7].However, the prevalence and characteristics of male depression are also thoroughly researched and discussed by scientists.Generally, masked depression in men (young men as well) can be concealed by substance abuse, somatization [8].
Traditional masculinity is the main risk factor for male vulnerability -the development under stress of maladaptive coping strategies, such as emotional suppression, reject of seek help, or substance abuse (especially alcohol).In our opinion, this basic male attitude exacerbates psychosocial stress vulnerability and explains the correlation between DD and high rates of behavioral disorders, delinquency, and suicide for young men [9].
The objective: to analyze the sexual characteristics of DD in a comorbid combination with SDB in youth.
The including criteria in the study were: (a) the young age as 15-18; (b) symptoms of DD due to the International Classification of Diseases for Mortality and Morbidity Statistics, 10th Revision (ICD-10) and high score on the Patient Health Questionnaire (PHQ9, ≥ 10).All participants hadn't an experience or current of psychotic episodes, organic brain disorders, substance use within the past 3 months.
For diagnostic reasons, we used a semi-structured clinical interview and evaluated patients' depression rating by PHQ-9.The study upheld ethics, protecting participants' rights, welfare, and confidentiality by bio-ethic guidelines of Shupyk NHU of Ukraine.
Statistical analysis of the data was performed using IBM SPSS Statistics.In our study between two sex groups were compared using the Chi-squared test.

RESULTS AND DISCUSSION
According to the results of the depression level in boys and girls using the PHQ9 scale, the groups were comparable: respectively on average 17.2±1.06and 16.46±1.77points (Ме±SD).This showed that there was no sex difference in the severity of depression.Even a comparison of the frequency highest scores on the scale (the moderately severe depression, ≥ 20) did not reveal a significant sex difference: 15 cases among girls (40.5%) and 2 cases among boys (18.2%; p=0.1734).However, among girls there was a tendency for moderate and severe depression to prevail.But these figures require further study, as this study included a much smaller number of boys than girls.
The inclusion criteria for the study did not include the presence of manifestations of SdB.However, in the diag-nosis all patients, taking into account the severity of their depression, were found to have some manifestations of SdB (Tab.1).
The data obtained in middle adolescence showed that most often DD is accompanied by external forms of SdB, specifically non-suicidal self-harm or excoriation, which are significantly almost twice as prevalent in girls (p=0.0099).In all cases of cutting or excoriation, patients reported about the repeated suicidal thoughts or persistent suicidal tendencies at the severe onset of DD.
All other SdB' features had no statistical difference in the groups by sex.But persistent suicidal tendencies and suicidal fantasies prevailed among boys, and suicidal thoughts and multiple suicide attempts prevailed among girls.Also, one-off suicide attempt was found only among girls (10 cases).
Important data were obtained when analyzing the distribution of clinical syndromes in the examined patients (Tab.3).That we found such syndromes as hystericaldepressive, depressive-hypochondriacal, depressive-dysphoric, and dysphoric syndromes only in girls.And hysterical-depressive syndrome was the most common -in one third of all cases in both groups (29.2%).
According to the sex differences, the study also revealed a statistically significant prevalence of depressiveobsessive syndrome among young men (45.4%) compared to women (8.1%; p=0.0035).In addition, statistically significant results were received for the prevalence of cases depressive syndrome in comorbidity with anxiety-phobic and obsessive symptoms as sum among young men -7 people (63.64% in this subgroup) compared to girls -5 people (13.51% in this subgroup; p=0.00075).This indicates the advantage of a comorbid combination of depres-  A serious variant of DD is a comorbid burden of depressive syndrome with depersonalization-derealization syndrome, which is often a complication of hystericaldepressive syndrome by the mechanism of dissociation.In our study, the combination of hystero-depressive, depressive-depersonalization-derealization and depressive-dysphoria syndromes in girls amounted to 24 cases (64.86%), and in boys -only 1 case (9.1%) with depressive-depersonalization-derealization syndrome as a burden of severe depression (p=0.00115).
An unexpected outcome of the study was the tendency to predominance of bisexual identification among girls (n=8; 21.6%), compared to one case among boys (9.1%; p=0.35).
All these data are an important result for further study and the appropriate focusing for complex psychopharmacological and psychotherapeutic interventions.
The following are clinical cases of sex differences in middle adolescence that were identified in the study.

Case study 1
Male V., 16 years old, 11th grade of the Lyceum.He is the only child in the family.In the family, he has a closer relationship with his mother.His relationship with his father is distant, without emotional manifestations: «I do not communicate with him.He only controls how I'm studying, he is not interested in anything else, scolded me for my grades and punishes me when I did not want to do my homework».V. notes that from elementary school until now he always felt anxiety of failing regarding school duties.
Previously, he had friends, but now he prefers to be alone and rarely communicates with them.He doesn't use alcohol or drugs.
Periods of depressed mood and suicidal thoughts first appeared when V. was still in elementary school: «Once, when I was 9 years old, in the third grade, a new very strict teacher gave me a «D» in three subjects in one day.I knew my father would beat me.I felt hopeless at the time.I was exhausted from being scolded for my grades any times.I thought it would be better to die».
His first psychological help with a positive effect was about three years ago due to «moral fatigue and melancholic mood».Within half a year before this visit, he noticed a sig-nificant decrease in activity, difficulties in studying, unwillingness to engage with his favorite hobbies («For the last few months I haven't been interested in the things I loved: photography and cycling»), sleep disturbances.His mental health significantly worsened after the school year began: «I must be admitted to a university, pass my exams successfully, but I have neither desire nor energy for studying.Basically, I have no idea that I want in the future, I can't even imagine my future».He stopped studying, socializing, or even leaving a room.The majority of the time was spent in his phone: «I was listening music, browsing, sometimes chatting with someone...I don't want to communicate with anyone anytime, especially my parents.It's to me only feel sorry for mom».V. notes permanent suicidal thoughts during these past three months: «I was burned out.I had suicide thoughts practically everyday, I couldn't handle them, and wanted them to be over at the fast time».He had planned suicide one week before the diagnostic interview: «I was planning hanging himself, had a rope ready, but mom called, I talked with her, and I became relieved so I didn't do it».
At the diagnostic exam, he responds unwillingly to the questions, pausing for a while.The mood is significantly depressed.Facial expressions frozen.Cognition was logical but slow.He expresses strong suicidal tendencies as well as ideas of self-humiliation: «I constantly feeling tired.I'm so annoyed that I've lost any interest in life, I can't handle it.I wanna leave these worries... Thoughts of hanging myself almost daily.There's nothing to help me».Deeply immersed in own feelings without reflexity and critical self-attitude.A score of 25 (severe depression) on the PHQ9 was founded.
This case study represents typical examples of Severe Melancholic Depression as variant of DCD in adolescent male with previous depressive episodes on background fathers' excessive demands, loneliness, and a combination of fear and pessimism about future.He had been hypothymic mood, sadness for several years, and met certain clinical criteria for Dysthymia.This depressive episode might be considered Hikikomori syndrome according to manifestations as reclusiveness, abandonment of aspirations, lack of socialization and social phobia.Importantly, manifestative features of SdB appeared in V.'s childhood.Therefore, in the severe depression his suicidal thoughts were transformed into persistent suicidal intentions and with a suicide decision was made.In this case, suicidal behavior is a complicating comorbidity of relatively severe DCD.Case study 2 Male S., 17 years old.A 1st-year university student.Has good and trusting relations with his mother and stepfather, however, he doesn't believe that they can do anything for him: «They are tolerating me already and do everything possible for me».There is no relationship with his own father.He has two older siblings, 27 and 23 years old, with whom he communicates with formally.
Until he was 15 or 16, he was quite shy and withdrawn, therefore his relationships with his peers were quite difficult: «I wanted to be cool, likeable, and the center of attention».He takes any kind of criticism by other people sharply.In his childhood and adolescence, he was prone to constantly «scrolling and rethinking in his head» any of his actions, often feeling anxiety and guilt of oneself.S. doesn't complain to his parents and teachers about bullying or reproach, but he has always «wanted to be better to achieve success later in life, helping his mom who is working hard and to prove his brothers that he could achieve more than they could, that I'm better than they are».
As a 9-year-old child, S. hardly survived the death of his beloved grandfather, who had been struggling with cancer: «I witnessed a human being dying for the first time.After this there were fears for a long time that it could happen to me, I tried to somehow protect ourselves against these thoughts, I often wept, and had nightmares, there were thoughts that I would rather be dead, to avoid suffering», that could be considered as suicidal fantasies.
The first time was two months before the exam with a suspicion of DD: «I felt like everything I did didn't matter anymore.I couldn't sleep due to negative thoughts about the future.I don't like studying.I can't achieve anything in life.

Why should I keep living like that?».
A few weeks later his mental state worsened because he had broken up with his girlfriend: «When I felt terrible, she was became irritated and abusive.Afterwards, I had thoughts that I wasn't good enough, boring and unattractive, I couldn't be together with anybody, there wouldn't be anything good in future, I had neither willingness nor energy to deal with those life.I thought poorly about my girlfriend after breaking up, but then I heard she had broken her arm.Then I started thinking that it was my fault, even knowing it wasn't».On the background of further exacerbation of depression and obsessions:

«I have a «feeling that I can't keep my thoughts controlled. I'm scared of wishing anything wrong to anyone -family members, or friends, or even acquaintances -in case of something happening to them. Even more, I'm scared such thoughts might sneak unnoticed. What if this wish is realized, can I deal with it, knowing that it happened due to my thoughts? I understand that it's something morbid -these thoughts are the opposite of me, but I can't rest even for a minute because I'm afraid of forgetting that I thought about someone or remembered them. To deal with all this at least a little bit, I started to attach memories of people to a certain place, then try to avoid them around to prevent them from affecting anyone. I can't stand this pressure anymore, I'd rather die».
There were depressive symptoms with ideas of selfblame and self-abasement, acute obsessive-compulsive syndrome, and suicidal thoughts as dominated features at the diagnostic clinical exam -22 points for PHQ9 (severe depression).He understands the morbid background of his obsessions and compulsive behaviours.He actively seeks help, however, but doesn't believe in their effectiveness.This clinical case is a typical illustration of severe DCD development with acute comorbid obsessive-compulsive syndrome and exacerbation with suicidal thoughts due to an additional psychological trauma -relation breakup.The personal background of S.' developing DCD is also important: a tendency to obsessions on the background of long-term anxiety and hypothymia caused by the emotional overtense, loneliness (despite having good family relationships), adolescence ambitions with intolerance of criticism and non-acceptanc, and infantile idealizations about one's own success and disappointment in reality.Important point is that S. has been experiencing all neurotic symptoms and manifestations of SdB (such as suicidal fantasies and thoughts) since childhood.In this case, the suicidal thoughts are the secondary complicating comorbidity component of the combination of severe depressive syndrome and acute obsessive-compulsive syndrome as part of complex comorbid DCD (F 92.0).

Case study 3
Girl O., 17 years old, is studying in the 11th grade, then in the 1st year of college.She is the only child in the family.In her opinion, the family relationships were not warm and trusting.The parenting style was authoritarian.О. notes that it was never accepted to show emotions in the family: «The word 'family' makes me sick».She believes that her father often devalues her problems and mental state.He is constantly scolding her and accusing that she has bad attitude towards school, and he's saying that she manipulates her mental disturbances: «They're saying any times that if it weren't for us, I wouldn't have succeeded in anything.Everything I have is thanks to them».However, at the diagnostic meeting father emphasizes that daughter «does nothing at home, does not help and does not want to study -I don't understand whether it's laziness or illness».He doesn't believe that this is mainly due to the daughter's mental problems and the family situation.Father believes there are no reasons for that: «We already make everything for her».The patient's mother takes an interest in the life of her daughter, but according to O.: «I don't trust her, so I'll never share anything with her».The relationship with the girl's grandmothers is also negative.
O. noticed that in elementary school she was not like others, so she wasn't treated well by peers: «It wasn't only abuse, but fights, once I was fighting against five boys».The patient notes that «in this school it was accepted that boys are against girls, so I started to be afraid of boys».She notes the teacher's bad attitude: «Sometimes she would beat me and others with a wet rag when I didn't understand something or couldn't answer anything correctly.I thought it was normal, then I told my parents, but they did nothing».Between the ages of 12 and 14, O. was forced to change schools due to her mother's business trip to one of the post-Soviet countries.Her parents chose a religious school for her, although she considered herself an atheist: «I was very far from anything religious».While studying at this school, she again faced bullying from her peers: «I was a stranger there, not like them, and they always bullied me».
After the move, she felt very lonely.When she returned with family to Ukraine, in high school, her relationships with her peers became difficult again: «I just wanted it to be over as fast as possible».She first sought help from a psychologist in 14 years old because of with her problems with family' and peers' relationships difficulties.This psychiatric diagnostic was referred by a psychologist and the parents' request that O. refuses to study at school, has sleep disturbances, severe irritability, and poor appetite.A week before this diagnostic meeting, she had already been examined by a psychiatrist with a conclusion of severe depression and personality disorder, but her father decided to get a second opinion.
At the diagnostic exam extremely tense, suspicious: «I keep thinking about how to hide every time, in case I am attacked».Pose «twisted into a knot».The mood is depressed but she obviously demonstrative in self-expression with over-valued ideas of self-deprecation and selfjustification: «I'm extremely blunt and I just can't cope with everything in my head, I don't want to live anymore, I'm not good for anything anyway and only a burden to my parents».Girl confessed that she has self-harmed: «It happens almost every day, but I hide it».
O. talked more openly about anamnesis and herself ideas at her second visit (while on antidepressants).In the childhood she couldn't express her emotions because «it would upset my parents, and I would hide at night and cry», and when O. was already 12 years old, she found a way to relieve severe anxiety and mental anguish: «I was cutting my arms or legs, and my parents didn't even know about it because they weren't looking to me».Meanwhile girl fantasized about suicide at the first time.Later, she began «fantasizing» another way: «I was about 13 when I imagined myself at bedtime, it was my own way to escape from reality's hell.Then I named the first face as 'personality', it had all my negative characteristics: aggressiveness, tearfulness, trustingness».Later, the patient distributed these characteristics among other «personalities».The past 6 months before exam O. had developed about 30 internal personalities: «They are all different.And I cannot understand the way they will appear.Sometimes personalities can interact with each other without me, but I am the main leader.Sometimes I cannot always control them, because some of them try to destroy the negative in me and me in total as well».At the meeting the girl said that she had 41 personalities, which she divided into certain groups: «aggressive, vulnerable, music addicted, etc».«Sandra is the most aggressive, she intervenes when there is a risk of a fight and she has to defend me».
O. identifies himself as a bisexual person: «Most of my personalities are female, but there are also bisexual ones».Her first sexual attraction to a girl-friend occurred when she was 14 years old, and shortly afterwards O. told her parents about it.They didn't support her: «Although mom accepted it, she still has hopes that I'll become 'normal'.Father actually considers that I'm healthy and lazy, and when I tell him about my passions, he says that they're fiction».O. has a relationship with a transgender girl now.
At the second meeting, she demonstrated intense emotion when talking about problems in the relationship with parents and the school.She had demonstrative behaviour with emotional gestures, tends to use rude speaking and swearing.Laughs at her inner feelings, which looks like an emotional paradox.She expressed like suicidal ideas: «I've had enough of life», but at the same time notes that «as long as I can control my head in some way, there is not a time to do anything with myself, but I can break down at any time».Her last time self-harm was a weeks ago, when she had conflicts with a friend and then with her parents.The PHQ9 score was 21 (severe depression).
This case is a typical example of the development of a severe hystero-depressive variant of DCD (F 92.0) in a girl, with depersonalization symptoms, suicidal fantasies, and self-injuries were comorbid.Constant misunderstandings in relations with parents, especially their nullification of the girl's feeling and numerous long-term psycho-traumatic circumstances with bullying in different school groups became the basis for the gradual development of multiple personality disorder with bisexual identity.In this case, the manifestations of dissociative disorder and SdB developed as a burdensome pathological variant of the girl's psychological defense in long-term distress.The severity of this case is associated with the bad prognosis towards the development of borderline personality disorder and the risk of an impulsive suicidal decision against the background of any additional psychotraumatic challenge.
All of these clinical cases demonstrate the critical importance of family history in the development of severe DD in middle adolescence, namely the deviant childparent relationships, including repeated psychotraumatic situations as the bullying in the family and at school.

CONCLUSIONS
According to the results of the our pilot study, it can be argued that DD have 100% comorbidity with SdB in middle adolescence.
Despite the comparability of groups of boys and girls by nosologies and severity of depression, significant sex differences were found in the formation and course of DD with comorbid manifestations of SdB.Thus, most often, non-suicidal self-injury or excoriation was combined with DD, which significantly prevailed in girls.
The data on the diagnosed clinical syndromes in the groups showed that hysterical-depressive, depressive-hypochondriacal, and depressive-dysphoric syndromes were detected only in girls with hysterical-depressive symptoms dominating among them.The combination of cases of hysterical-depressive and depressive-depersonalizationderealization and and depressive-dysphoria syndromes syndromes as a severe variant of DD was significantly more common among girls as well.They also showed a tendency to predominance of bisexual identification.In contrast, the depressive-obsessive and anxiety-depressive syndromes was more typical for young men.
These clinical cases present typical examples of severe DD in adolescence, taking into account sex specificity of them, as well as the incredible importance of psychotraumatic family history in their development and course.

Table 1
SdB' features in the patients by sex, abs (%)

Table 2
Variants of DD in the patients by sex, abs (%) sive syndrome with a spectrum of anxiety-phobic-obsessive symptoms among youngsters in middle adolescence.Such examples are given in clinical cases.

Table 3
Clinical syndromes in the patients by sex, abs (%)