title: Self-harm and suicidal acts: a suitable case for treatment of impulsivity-driven behaviour with repetitive transcranial magnetic stimulation (rTMS).
abstract: CONCLUSIONS
  Suicidal thinking, self-harm and suicidal acts are common, although determining their precise prevalence is complex. Epidemiological work has identified a number of associated demographic and clinical factors, though, with the exception of past acts of self-harm, these are non-specific and weak future predictors. There is a critical need shift focus from managing 'suicidality-by-proxy' through general mental health treatments, to better understand the neuropsychology and neurophysiology of such behaviour to guide targeted interventions. The model of the cognitive control of emotion (MCCE) offers such a paradigm, with an underlying pan-diagnostic pathophysiology of a hypoactive prefrontal cortex failing to suitably inhibit an overactive threat-responding limbic system. The result is a phenotype - from any number of causative gene-environment interactions - primed to impulsively self-harm. We argue that such neural dysconnectivity is open to potential therapeutic modification from repetitive transcranial magnetic stimulation (rTMS). The current evidence base for this is undoubtedly extremely limited, but the societal and clinical burden self-harm and suicide pose warrants such investigation.
  
  
  BACKGROUND
  K.B. is the Editor ofBJPsych Open, but had no editorial involvement in the review or decision process regarding this paper.
  © The Royal College of Psychiatrists 2015. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) licence.
authors.affiliation: , Oxleas NHS Foundation Trust, London, and Cognition, Schizophrenia & Imaging Laboratory, Institute of Psychiatry, Psychology and Neuroscience, King's College London, UK.
authors.forename: Derek K
authors.initials: DK
authors.lastname: Tracy
authors.affiliation: , Cognition, Schizophrenia & Imaging Laboratory, the Institute of Psychiatry, Psychology, and Neuroscience, King's College London, UK; South London and Maudsley NHS Foundation Trust, London, UK.
authors.forename: Sukhwinder S
authors.initials: SS
authors.lastname: Shergill
authors.affiliation: , Department of Psychosis Studies, the Institute of Psychiatry, Psychology, and Neuroscience, King's College London, and South London and Maudsley NHS Foundation Trust, London, UK.
authors.forename: Anthony S
authors.initials: AS
authors.lastname: David
authors.affiliation: , Research Department of Clinical, Educational, and Health Psychology, University College London, London, UK.
authors.forename: Peter
authors.initials: P
authors.lastname: Fonagy
authors.affiliation: , Department of Psychiatry, University of Cambridge, and East London NHS Foundation Trust, London, UK.
authors.forename: Rashid
authors.initials: R
authors.lastname: Zaman
authors.affiliation: , Department of Psychiatry, University of Toronto, Ontario, Canada.
authors.forename: Jonathan
authors.initials: J
authors.lastname: Downar
authors.affiliation: , Wolfson Institute of Preventive Medicine, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, UK.
authors.forename: Emma
authors.initials: E
authors.lastname: Eliott
authors.affiliation: , Wolfson Institute of Preventive Medicine, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, UK.
authors.forename: Kamaldeep
authors.initials: K
authors.lastname: Bhui