Subclinical self-harm: range of behaviors, extent, and associated characteristics

'Am I really the priority here?': help-seeking experiences of university students who self-harmed

BACKGROUND

Self-harm is a significant problem in university students because of its association with emotional distress, physical harm, broader mental health issues and potential suicidality. Research suggests that fewer than half of students who have self-harmed seek professional help when at university.

AIMS

This study aimed to explore the help-seeking journeys of university students who had engaged in self-harm, to identify perceived facilitators and barriers to securing both formal and informal support.

METHOD

Participants comprised 12 students who had self-harmed during their university tenure. Engaging in two semi-structured interviews over the academic year, they shared insights into their help-seeking behaviours and proposed enhancements to local services. Data underwent reflexive thematic analysis within a critical realist framework.

RESULTS

The analysis identified four themes: 'The initial university phase poses the greatest challenge', 'Perceived criteria for "valid" mental health problems', 'Evading external judgements, concerns and consequences' and 'The pivotal role of treatment options and flexibility in recovery'.

CONCLUSIONS

Students felt isolated and misunderstood, which amplified self-harming tendencies and diminished inclinations for help-seeking. A prevalent belief was that for self-harm to be deemed 'valid', it must manifest with a certain severity; however, concurrent fears existed around the ramifications of perceived excessive severity. Participants expressed a desire for streamlined pathways to mental health resources, encompassing both university and external mental health services. Insights from this study could guide future research and inform current service paradigms within academic and healthcare systems.

Childhood maltreatment, traumatic experiences, and posttraumatic stress disorder in pathological skin picking: An online case-control study

OBJECTIVE

Although traumatic stress including childhood maltreatment (CM) has a profound impact on mental health, its relation to pathological skin picking (PSP) has been understudied and results remain inconclusive. Likewise, posttraumatic stress disorder (PTSD) as the most typical sequelae of traumatic stress has hardly been investigated in those with PSP. The objective of our online case-control study was to shed further light on this issue.

METHODS

Using an anonymous online survey, 325 adult participants with PSP defined by Skin Picking Scale-Revised (SPS-R) scores ≥ 7 as well as Skin Picking Impact Scale (SPIS) scores ≥ 7 were administered the Childhood Trauma Questionnaire (CTQ), the Short Screening Scale for DSM-IV PTSD (PTSD-7) including a list of traumatic events, and a brief measure of psychopathological distress. They were compared to an age-, sex-, and education-matched control group recruited online by means of analyses of variance (ANOVA).

RESULTS

The PSP sample scored significantly higher on the CTQ dimensions of sexual and emotional abuse as well as emotional neglect with small to moderate effect sizes (d between 0.27 and 0.49). Accounting for psychological distress, the only significant difference related to emotional abuse with a small effect (d = 0.23). Participants with PSP reported significantly more traumatic experiences in adulthood than the control group (59.1% vs. 38.2%; χ²_{(1; N=638)} = 28.02, p < .001). Among those with PSP, a probable diagnosis of PTSD was found in 44 (13.5%) compared to zero cases in the control group.

CONCLUSIONS

Our findings indicate that emotional abuse in childhood may be of relevance in skin picking. Since exposure to traumatic events in adulthood as well as PTSD seem to be more frequent in those with PSP compared to a control group, it might be worthwhile to consider these factors in the assessment of patients with skin picking.

Dark personalities and general masochistic tendencies: Their relationships to giving and receiving sexualized pain

Recent research has shown that a tendency to harm others goes hand in hand with a tendency to harm oneself. The present two studies further supported the notion that the joy of harming others and oneself has a common core by showing positive relationships between dark personality traits (particularly psychopathy) and sexual masochistic preferences and between general masochistic tendencies and sexual sadistic preferences. Despite the overlap between dark personality traits and general masochistic tendencies, they independently predicted the engagement in sexual sadomasochism. These relationships statistically held when controlling for the impact of basic personality (Study 1). Study 2 found that self-enhancement, openness to change, and low conservation values serve as motivators for a person's attraction to sexual sadomasochism and shed some light on the differences between sexual sadomasochism and the Dark Tetrad. Overall, people who score relatively high on dark personalities and masochism are particularly predisposed to engage in sexual sadomasochism, in both the dominant and the submissive roles.

Exploring the suicidal continuum: Deliberate self-harm diversity and severity as predictors of suicidal ideation and suicide attempts

Deliberate self-harm (DSH) in adolescence is a predictor of suicidal thoughts and behaviors (STBs). However, there is still a lack of research systematizing the association between DSH and STBs. Therefore, our main goal was to analyze if DSH diversity and severity predicted suicidal ideation and suicide attempts. Our sample comprised 237 Portuguese adolescents and young adults with a history of DSH, from community (80.2%, n = 190) and clinical (19.8%, n = 47) settings, aged between 14 and 23 years (M = 17.31, SD=1.36). Results showed that DSH diversity and severity were significant predictors of suicidal ideation and suicide attempts. These results were further discussed, underlining the impact that DSH has for suicide risk and highlighting the need to address further variables to understand these suicidality trajectories.

Psychometric properties of the persian version of the inventory of statements about self-injury (ISAS)

BACKGROUND

Non-suicidal self-injury (NSSI) is a serious public health problem prevalent among adolescents and young adults. The present study examines the factor structure, internal consistency, and validity of the Persian version of the Inventory of Statements About Self-injury (ISAS), a self-report measure designed to comprehensively assess non-suicidal self-injury (NSSI).

METHODS

A total of 655 Iranian school-attending adolescents completed study measures online, and 246 youth (37.70 %) (M age = 15.38, SD ± 0.50; 53 % female) reported a history of NSSI at least once during their lifetime.

RESULTS

Confirmatory factor analysis supported the proposed two-factor model of ISAS (i.e., Interpersonal and Intrapersonal dimensions), which were internally consistent and yielded direct associations with converging correlates (e.g., depression, anxiety, irritability, and anger).

CONCLUSIONS

Findings indicated that the Persian version of the ISAS has sound psychometric properties and is a valid and reliable self-report measure of NSSI.

Disentangling acculturation and enculturation intergenerational gaps: Examining mother-youth value discrepancies and mental health among Mexican-descent college students

OBJECTIVE

To test the acculturation gap hypothesis by examining mother-youth value discrepancies (both acculturative and enculturative) and their association with mother-youth acculturative conflict and youth mental health outcomes.

METHOD

Participants were 273 Mexican descent college students attending a large, public, Hispanic Serving Institution (HSI) in West Texas (72% women). The participants' ages ranged 18-25 years (M = 19.33 years; SD = 1.54 years).

RESULTS

Three models assessed the relationship between mother-youth value discrepancies and mental health outcomes (suicidal ideation, non-suicidal self-injury, and depressive symptoms) as mediated by mother-youth acculturative conflict. Consistently, Mexican heritage cultural values were related to mental health outcomes while American cultural values were not.

CONCLUSIONS

The study found that increased mother-youth discrepancies on Mexican cultural values were associated with increased negative mental health outcomes. Our findings suggest that adopting or learning new mainstream American values does not substitute for the Mexican cultural values that protect against negative outcomes.

Obsessive-compulsive symptoms in female patients with an eating disorder with or without impulsive non-suicidal self-injury

BACKGROUND AND AIMS

In the present study, we investigated differences in obsessive-compulsive (OC) symptoms in patients with an eating disorder (ED) with or without recent/lifetime impulsive non-suicidal self-injury (NSSI). We included 429 female inpatients with an ED, of whom 31.9% engaged in recent impulsive NSSI and 56.4% in lifetime impulsive NSSI.

MATERIALS

They filled out the Eating Disorder Evaluation Scale, the Self-Injury Questionnaire-Treatment Related and the Padua Inventory-Revised (OC symptoms).

METHODS AND RESULTS

Patients with anorexia nervosa, binge-eating/purging type (AN-BP) and bulimia nervosa (BN) engaged more frequently in recent/lifetime impulsive NSSI compared to patients with anorexia nervosa, restrictive-type (AN-R). Two MANCOVAs with OC symptoms as dependent variables, and ED subtypes and recent/lifetime impulsive NSSI as independent variables controlling for age and body mass index showed the main effects of ED subtypes and recent/lifetime impulsive NSSI. Patients with AN-BP reported significantly more impulses (i.e., being afraid of losing control over motor behaviours) compared to patients with AN-R and BN. ED patients with impulsive recent/lifetime NSSI scored significantly higher on all OC scales compared to patients without NSSI.

DISCUSSION AND CONCLUSION

In sum, the presence of recent/lifetime impulsive NSSI in patients with an ED seems to be related to more severe OC symptoms. Hence, this comorbidity needs to be addressed in psychotherapy, such as in transdiagnostic cognitive behavioural therapy for EDs.

Task Control Deficit in Individuals With Non-suicidal Self-Injury

Background: Numerous people in clinical settings who have experienced repeated self-injuries explain their non-suicidal self-injury (NSSI) as "habitual" or due to "difficulty avoiding impulses related to NSSI." Previous studies present retrospective reports, where they experience frequent self-injurious urges and try to resist but fail. However, no study has directly investigated repeated behavioral control problems of people who engage in chronic NSSI through behavioral measurements in an experimental setting. The current study sought to investigate whether people who repeatedly attempt NSSI demonstrate deficiency in task control ability called the object-interference (O-I effect). Methods: The current study performed object interference tasks on 90 participants, of which 45 were those who reported repeated NSSI while 45 comprised the control group. Results: We observed delayed reaction times for object stimulus compared to abstract stimulus in the NSSI group, indicative of the object interference effect. This reflects task control deficits and difficulties in NSSI related behavioral control in the repeated NSSI group. When NSSI tools were additionally presented as a target stimulus, longer reaction times and more errors were observed in the NSSI group compared to the control group. Discussion: The current study discusses the clinical implications of the results from diagnostic point of view and provides suggestions for future research for treatment and prevention.

The psychometric properties and clinical utility of the Norwegian versions of the deliberate self-harm inventory and the inventory of statements about self-injury

Deliberate self-harm (DSH) is a widespread transdiagnostic health problem with increasing prevalence among adolescences, and young adults. It is therefore essential to effectively chart the epidemiology of DSH, as well as to assess the efficacy of interventions designed to modify this behavior. The aim was to translate and analyze the psychometric properties of the Norwegian versions of two instruments designed to assess DSH: the Deliberate Self-harm Inventory (DSHI) and the Inventory of Statements About Self-Injury (ISAS), as well as to assess the prevalence of DSH within a nonclinical Norwegian adult population. Of the 402 participants who completed a questionnaire packet comprising the DSHI, ISAS, general questions about DSH, and other related measures, 30.6% reported some form of DSH. Those with a history of DSH reported greater difficulties with emotion regulation than those without. Participants with and without a history of DSH did not differ in unrelated constructs, including social desirability. The frequency of specific DSH behaviors was in accordance with previous research, with cutting being the most frequent. The factor structure of DSH functions in the Norwegian ISAS was generally comparable to the factor structure of the English version. Overall, results indicate that: a) the Norwegian versions of the DSHI and ISAS behave as expected and in accordance with prior research in other languages and other populations, and b) both the DSHI and ISAS have high internal consistency and adequate construct, convergent, and discriminant validity, and may be applied to evaluate DSH in adult Norwegian populations.

Body-focused repetitive behaviors and non-suicidal self-injury: A comparison of clinical characteristics and symptom features

Body-focused repetitive behaviors (BFRBs) and non-suicidal self-injury (NSSI) are recognized as distinct categories in the DSM-5. However, definitions and assessment of NSSI sometimes encompasses behaviors similar to BFRBs, and little data exist about their clinical differences. The current study examined clinical characteristics and symptom features associated with NSSI vs. BFRBs. The current sample included 1523 individuals who endorsed moderate to severe NSSI (n = 165) or BFRBs: hair pulling group (n = 102), skin picking group (n = 216), nail picking group (n = 253), nail biting group (n = 487), and cheek biting group (n = 300). Responders were asked to complete questionnaires on clinical features relevant for BFRBs and NSSI. NSSI and BFRBs had significant differences on several clinical features. Individuals in the NSSI group were more likely than individuals with BFRBs to report engaging in the behavior for social-affective reasons (i.e., to get out of doing something, or receive attention from others). Individuals in the NSSI group were also more likely to engage in the behavior to regulate tension and feelings of emptiness, and to experience relief during the act. In contrast, individuals in the BFRB groups were more likely to engage in the behavior automatically without reflective awareness, to reduce boredom, or to fix appearance. The NSSI group obtained significantly higher scores on questionnaires assessing stress, anxiety, depression, and harm avoidance. Overall, the results showed several notable differences between NSSI and BFRBs that are consistent with clinical literature and definitions of these problems in the DSM-5.

Development and Factorial Validation of the Inventory of Deliberate Self-Harm Behaviours for Portuguese Adolescents

Deliberate self-harm (DSH) is a public health problem that mainly affects adolescents and young adults. Evidence suggests that multiple methods are used with a self-aggressive intent. The present article focuses on the development and factorial validation of the Inventory of Deliberate Self-harm Behaviours for Portuguese adolescents. This instrument assesses the lifetime frequency of 13 DSH methods, with and without suicidal intent. Study 1 consisted of an exploratory factor analysis with a sample of 131 adolescents with a reported history of DSH. Results revealed a three-factor structure with acceptable internal consistency: High Severity DSH, Mild Severity DSH, and Substance Use DSH. After item reduction, this structure was tested in Study 2 through a confirmatory factor analysis with an independent sample of 109 adolescents also with a history of DSH. Results showed an acceptable model fit. This instrument presents a solid structure and acceptable psychometric properties, allowing its use in further research.

Disgust, shame and the psychosocial impact of skin picking: Evidence from an online support forum

This article examines the accounts of individuals who problematically pick their skin and explores their subjective experiences. In total, 100 problem disclosure statements were taken from posts made to a publicly accessible online skin picking support forum. These posts were systematically analysed using thematic analysis. Themes of disgust, shame and psychosocial avoidance dominated the analysis and appeared central to the experience of skin picking. Skin picking was shown to be a heterogeneous experience with a complex emotional profile. We argue that disgust, shame and related avoidance behaviour should be considered when conceptualising skin picking and considering treatment interventions.

Skin picking in patients with obesity: Associations with impulsiveness and self-harm

Previous studies suggest elevated prevalence rates of skin picking and self-harm in patients with obesity compared to individuals in the general population. Hence, further studies should investigate prevalence rates and correlates of skin picking in this population - especially its differentiation to self-harm. Skin picking and obesity are both associated with specific facets of impulsiveness. This relation should be explored to shed light on potentially shared mechanisms in etiology. Therefore, the present study examined the occurrence of skin picking and its associations with impulsiveness and self-harm in a sample of pre-bariatric surgery patients with obesity class II/III. Within the routine preoperative psychiatric evaluation, a total of 139 bariatric surgery candidates (78% female, BMI range 35-69) completed a self-report questionnaire assessing sociodemographic variables, anxiety, depression, self-harm, impulsiveness, and skin picking severity (urges: frequency, intensity, controllability; behavior: frequency, intensity, controllability; resistance, emotional distress, impairment, and avoidance). Ten participants (7.2% of the sample) reported recurrent skin picking leading to skin damage, repeated attempts to decrease skin picking, and psychosocial impairment (emotional distress, impairment in functional areas, avoidance) due to skin picking. In line with previous findings, skin picking severity shows a medium correlation with attentional impulsiveness. The majority of self-harm types were not associated with skin picking severity. The current study reveals a high occurrence of skin picking compared to the general population. The results indicate an association between skin picking severity and attentional impulsiveness. Further research is needed to investigate the differentiation of skin picking and self-harm in more detail.

Body-focused repetitive behaviors: More prevalent than once thought?

Body-focused repetitive behaviors (BFRBs), such as hair pulling, skin picking, and nail biting are common habits, but their pathological manifestations have been considered rare. Growing evidence suggests pathological forms of these behaviors can be conceptualized as a class of related disorders. However, few previous studies have examined the collective prevalence of related pathological BFRBs. The current study examined the self-reported prevalence of current (past month) subclinical and pathological BFRBs in a large (n = 4335) sample of college students. The study also examined the chronicity and impact of these behaviors. Results showed that 59.55% of the sample reported occasionally engaging in subclinical BFRBs, and 12.27% met criteria for a pathological BFRB, suggesting these conditions may be quite common. Of the various BFRB topographies, cheek biting was the most common. Both subclinical and pathological BFRBs tended to be chronic (i.e., occurring for longer than 1 year). Although persons with pathological BFRBs were distressed about their behavior, few experienced functional impairment or sought help for the behavior. Implications of these findings for the conceptualization and treatment of body-focused repetitive behaviors are discussed.

Self-Esteem and Anger in Borderline Patients With Self-Injury Behavior

Anger and low self-esteem characterize borderline individuals, yet little is known about their role and impact in the presence or absence of self-injury behavior. The present study aimed to investigate the impact of anger and self-esteem in borderline patients and whether these variables distinguish these patients with and without self-injury. Patients were recruited from a psychiatric service and were evaluated for self-esteem and anger. Additionally, impulsivity and symptoms were assessed. Two groups were compared, one with self-injurious behavior (n = 18) and another one without it (n = 23). Those who injure themselves seem to have a lower self-esteem (p < 0.001), yet the strengthening of self-esteem seems to have different outcomes, according to the presence or absence of self-injury. Anger and self-esteem seem to influence the severity of diagnosis, but only in patients who self-injure. Anger and self-esteem may influence borderline patients differently according to the presence or absence of self-injury.

Restrictive eating and nonsuicidal self-injury in a nonclinical sample: Co-occurrence and associations with emotion dysregulation and interpersonal problems

Disordered eating frequently co-occurs with nonsuicidal self-injury (NSSI), and evidence suggests that the co-occurrence of these behaviors is associated with heightened emotion dysregulation. However, little is known about the relationship between restrictive eating and NSSI, and the significance of their co-occurrence. This study examined cross-sectional associations between self-reported restrictive eating, NSSI, and putative mechanisms of emotion regulation and interpersonal problems in a non-clinical sample of undergraduate students (N = 98, 80.6% female), using the Dietary Restriction Screener (Haynos & Fruzzetti, 2015), Deliberate Self-Harm Inventory (Gratz, 2001), Difficulties in Emotion Regulation Scale (Gratz & Roemer, 2006), and Inventory of Interpersonal Problems-Personality Disorders-25 (Kim & Pilkonis, 1999). Hierarchical logistic regression analyses indicated that restrictive eating was associated with NSSI above and beyond the influence of binge eating, purging, and relevant covariates (B = 2.04, p < 0.001). In addition, multivariate analyses of variance revealed that the co-occurrence of restrictive eating and NSSI was associated with greater difficulties accessing and implementing effective, rather than impulsive, emotion regulation strategies when distressed than either behavior alone (p < 0.001). Findings highlight the seriousness of restrictive eating even within a nonclinical sample, as it is associated with heightened probability of NSSI and clinical severity among those who engage in co-morbid NSSI. Healthcare providers are encouraged to screen for NSSI among individuals with restrictive eating. In addition, a focus on improving emotion regulation and interpersonal skills may enhance prevention and intervention efforts for individuals with co-occurring restrictive eating and NSSI behaviors.

Pathological Narcissism and Nonsuicidal Self-Injury

Few studies have examined associations between pathological narcissism and self-harm, but those that do indicate that narcissistic vulnerability (not narcissistic grandiosity) relates to self-harm. The current study extends this literature by investigating how facets of pathological narcissism assessed by the Pathological Narcissism Inventory relate to specific nonsuicidal self-injury (NSSI) behaviors assessed by the Inventory of Statements About Self-Injury using statistical models appropriate for non-normally distributed count data. In a sample of 1,023 undergraduate students, results revealed that facets of both narcissistic vulnerability and narcissistic grandiosity were differentially related to the endorsement and frequency of specific NSSI behaviors and higher-order latent NSSI factors (repetitive and impulsive), even after accounting for levels of borderline pathology. The clinical implications of these results are discussed.

Childhood maltreatment and non-suicidal self-injury: a systematic review and meta-analysis

BACKGROUND

Non-suicidal self-injury is being increasingly recognised as a prominent public health concern. Identification of early and modifiable risk factors is necessary to advance the screening and intervention efforts, particularly early detection of at-risk individuals. We aimed to examine childhood maltreatment, including its specific subtypes, in relation to non-suicidal self-injury.

METHODS

We did a comprehensive meta-analysis of childhood maltreatment (overall, sexual abuse, physical abuse and neglect, and emotional abuse and neglect) in association with non-suicidal self-injury. We also provided a qualitative review of mediators and moderators of this association. We identified relevant articles published from inception to Sept 25, 2017, through a systematic search of Embase, MEDLINE, and PsycINFO. We extracted continuous and categorical data and assessed for potential moderators using ten study characteristics. We generated random-effects models for analysis and evaluated for publication bias.

FINDINGS

We identified 71 publications that met eligibility criteria. Overall childhood maltreatment was associated with non-suicidal self-injury (odds ratio 3·42, 95% CI 2·74-4·26), and effect sizes for maltreatment subtypes ranged from 1·84 (1·45-2·34) for childhood emotional neglect to 3·03 (2·56-3·54) for childhood emotional abuse. Publication bias was not evident, except in the case of childhood emotional neglect. Across multiple maltreatment subtypes, we found stronger associations with non-suicidal self-injury in non-clinical samples.

INTERPRETATION

With the exception of childhood emotional neglect, childhood maltreatment and its subtypes are associated with non-suicidal self-injury. Screening of childhood maltreatment history in non-suicidal self-injury risk assessments might hold particular value in community settings, and increased attention to childhood emotional abuse is warranted.

FUNDING

National Institute of Mental Health.

Recent Suicidality in the General Population: Multivariate Association With Childhood Maltreatment and Adult Victimization

Three hundred and eighty-seven participants from the general population completed the Suicidality scale of the Detailed Assessment of Posttraumatic Stress (DAPS) and the Traumatic Events Survey (TES). Within the prior month, 14% of adults reported some degree of suicidal ideation and 2% reported an active or passive suicide attempt. Multinomial logistic analysis indicated that, as compared with nonsuicidal participants, age, childhood physical abuse, childhood sexual abuse, and childhood emotional abuse were associated with recent suicide attempts, whereas recent suicidal ideation without attempts was predicted solely by emotional abuse. In contrast, adult sexual or physical assaults were not associated with recent suicidality in any form.

Self-injurious behavior, emotion regulation, and attachment styles among college students in India

CONTEXT

Intentional self-directed acts of injury are the most common among adolescents and young adults. Developmental psychopathology theories that conceptualize pathways to self-injurious behaviors (SIBs) implicate insecure attachment representations and inadequate self-regulatory skills to cope with emotional distress.

AIMS

The study aimed to examine relationships between SIBs, attachment, and emotion regulation among college students.

MATERIALS AND METHODS

A total of 470 participants from undergraduate and postgraduate colleges completed the functional assessment of self-mutilation questionnaire, attachment style questionnaire, and the difficulties in emotion regulation scale.

RESULTS

Results indicated that 31.2% of the participants reported SIB in the past year, with the mean age of onset being 15.9 years. Moderate/severe forms of self-injury (e.g. cutting, burning) were reported by 19.8% of the sample. Self-injuring youth reported higher levels of anxious attachment, preoccupation with relationships and need for approval in relationships, and difficulties in all domains of emotion regulation. Logistic regression analysis identified preoccupation with relationships and impulse control difficulties as predictors of SIB.

CONCLUSIONS

The findings have implications for comprehensive interventions for self-injuring youth.

Impact of Childhood Abuse on the Risk of Non-Suicidal Self-Injury in Mainland Chinese Adolescents

Background

Childhood abuse has been associated with significant increases in non-suicidal self-injury (NSSI) behaviors in adolescents; however, only general definitions of this risk indicator have been examined. This study identified relationships between specific forms of childhood abuse and NSSI in mainland Chinese adolescents.

Method

A total of 14,221 cases were retained from an epidemiological study involving adolescents from junior and senior middle schools. Information relating to the perpetrator, perceived harm, timing of exposure to different types of childhood abuse, and NSSI were obtained. Logistic regression was used to analyze relationships between each form of childhood abuse and NSSI.

Results

Approximately 51.0% of the students reported at least one abusive childhood experience. Nearly one in four students (24.9%) reported that they had engaged in NSSI in the past 12 months. Each type of childhood abuse, occurring at any time within the first 16 years of life, especially in situations of continuous exposure, was significantly associated with NSSI. A significant graded relationship was found between number of abusive childhood experiences and NSSI. Students maltreated by parents or others were at high risk of engaging in NSSI, the risk was greater in students maltreated by both; students who had been exposed to childhood abuse with no perceived harm still demonstrated an elevated risk for NSSI. The pattern of associations did not vary by gender.

Conclusions

These findings suggest that experiencing any of various forms of childhood abuse should be considered a risk factor for NSSI during adolescence. Further research should focus upon psychosocial, neural, and genetic factors that might moderate or mediate the onset of NSSI in adolescents who have experienced childhood abuse.

Patterns of non-suicidal self-injurious behaviours among college students in India

BACKGROUND

Non-suicidal self-injurious behaviour (NSSI) is a growing concern among youth and rarely reaches the attention of mental health and medical services.

AIMS

The study explored the occurrence, methods, characteristics and reported reasons for NSSI among a sample of college students in India.

METHODS

A total of 470 participants from undergraduate and postgraduate colleges completed the Functional Assessment of Self Mutilation (FASM) questionnaire.

RESULTS

Results indicated that 31.2% of the participants reported NSSI in the past year, with the mean age of onset being 15.9 years. Moderate/severe forms of NSSI were reported by 19.8% of the sample. The most common method was self-hitting (15.2%) followed by cutting or carving skin (13.2%). A majority of self-injurers endorsed multiple methods of NSSI, and there were no significant gender differences in NSSI rates. The NSSI was performed both to regulate internal emotional states (automatic reinforcement) and to influence others in the environment (social reinforcement).The most commonly endorsed reasons for NSSI were 'to feel relaxed' and 'to get control of the situation', while the least frequently endorsed reasons were 'to make others angry' and 'to avoid college, work, or other activities'.

CONCLUSION

The findings underscore the need to increase the awareness and understanding of NSSIs and to plan targeted interventions among college youth.

Development of item bank to measure deliberate self-harm behaviours: facilitating tailored scales and computer adaptive testing for specific research and clinical purposes

The purpose of this study was to investigate the application of item banking to questionnaire items intended to measure Deliberate Self-Harm (DSH) behaviours. The Rasch measurement model was used to evaluate behavioural items extracted from seven published DSH scales administered to 568 Australians aged 18-30 years (62% university students, 21% mental health patients, and 17% community members). Ninety four items were calibrated in the item bank (including 12 items with differential item functioning for gender and age). Tailored scale construction was demonstrated by extracting scales covering different combinations of DSH methods but with the same raw score for each person location on the latent DSH construct. A simulated computer adaptive test (starting with common self-harm methods to minimise presentation of extreme behaviours) demonstrated that 11 items (on average) were needed to achieve a standard error of measurement of 0.387 (corresponding to a Cronbach׳s Alpha of 0.85). This study lays the groundwork for advancing DSH measurement to an item bank approach with the flexibility to measure a specific definitional orientation (e.g., non-suicidal self-injury) or a broad continuum of self-harmful acts, as appropriate to a particular research/clinical purpose.

Prevalence of nonsuicidal self-injury in nonclinical samples: systematic review, meta-analysis and meta-regression

Published prevalence estimates of nonsuicidal self-injury (NSSI) among nonclinical samples are highly heterogeneous, raising concerns about their reliability and hindering attempts to explore the alleged increase in NSSI over time. Accordingly, the objectives of this study were to investigate the influence of methodological factors on heterogeneity in NSSI prevalence estimates, explore changes over time, and estimate overall international NSSI prevalence. Results showed that methodological factors contributed over half (51.6%) of the heterogeneity in prevalence estimates, and, after adjusting for these factors, NSSI prevalence did not increase over time. Overall, pooled NSSI prevalence was 17.2% among adolescents, 13.4% among young adults, and 5.5% among adults. Clearly, development of standardized methodology in NSSI research is crucial if accurate estimates are desired.

Clinical specificity of acute versus chronic self-injury: measurement and evaluation of repetitive non-suicidal self-injury

Overall, previous studies on the prevalence of non-suicidal self-injury (NSSI) behaviors in the general population have stressed the importance of differentiating between occasional and repetitive NSSI, examining different severity levels (e.g., frequency and variety of methods), as well as investigating the diverse psychopathological correlates of NSSI. However, existing NSSI measures have not been explicitly developed by to comply with the NSSI diagnostic criteria proposed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). The purpose of this study is to develop a measure of repetitive NSSI by considering its essential features, as described in the proposed DSM-5 as well as in other clinically relevant aspects emerging from case reports. Two independent samples of participants (N1=383 young adults and 251 adolescents; N2=953 adolescents) belonging to the general population were involved in the present study. The questionnaire showed satisfactory fit statistics and reliably discriminated between occasional and repetitive self-injurers (Area Under Curve, AUC=0.755). The pattern of correlations with psychopathological measures confirmed a more clinically-compromised profile for repetitive rather than occasional self-injurers.

Post-Separation Abuse of Women and their Children: Boundary-setting and Family Court Utilization among Victimized Mothers

Continued abuse of themselves and their children is a concern for many mothers leaving intimate partner violence (IPV) perpetrating husbands. This research examines women's responses to abuse committed by ex-husbands with whom they had undergone custody disputes. In-depth, qualitative interviews were conducted with 19 mothers who had divorced IPV-perpetrating husbands between one and three years prior. Participants were located through publicly available family court divorce records and interviews were examined using analytic induction. Women's strategies to protect themselves and their children from abuse involved setting boundaries to govern their interactions with ex-husbands. Mothers often turned to family court for assistance in setting boundaries to keep children safe, but found that family court did not respond in ways they believed protected their children. Conversely, when women turned to the justice system for restraining orders or called the police for help against IPV, they generally found the justice system responsive.

Interpersonal and Intrapersonal Functions of Deliberate Self-Harm (DSH): A Psychometric Examination of the Inventory of Statements About Self-Injury (ISAS) Scale

Deliberate self-harm (DSH), commonly defined as the intentional, direct and non-suicidal destruction of one's body, appears to be common across both clinical and non-clinical populations. A recently developed measure of functions of DSH, the Inventory of Statements About Self-Injury (ISAS), was examined to test its two-factor model within a sample of members of online social networks. The approach adopted was to fit data from the scale to the Rasch measurement model, which is increasingly used to develop and/or assess scales. Two hundred and one (n = 201) participants aged over 18 years of age, who had engaged in DSH in the last 12 months, were recruited from online social networks’ DSH peer support groups to complete an online survey. An exploratory factor analysis supported interpersonal and intrapersonal factors based on 13 function domains. Furthermore, both factors demonstrated satisfactory fit to the Rasch model. Some local dependency was detected, and when addressed, it impacted on the alpha coefficient level for intrapersonal factor. This study is the first independent psychometric investigation of ISAS, further supporting the scale authors’ psychometric evaluations. Additional validation across different DSH samples is recommended.

Measuring engagement in deliberate self-harm behaviours: psychometric evaluation of six scales

BACKGROUND

Engagement in Deliberate Self-Harm (DSH) is commonly measured by behavioural scales comprised of specific methods of self-harm. However, there is a scarcity of information about the degree to which the methods relate to the same DSH construct although such scales are routinely used to provide a DSH total score. This study addresses the shortfall by evaluating the dimensionality of six commonly used behavioural measures of DSH.

METHODS

The DSH measures were Self-Injury Questionnaire Treatment Related (SIQTR), Self-Injurious Thoughts and Behaviors Interview (SITBI), Deliberate Self-Harm Inventory (DSHI), Inventory of Statements About Self-Injury (ISAS), Self-Harm Information Form (SHIF) and Self-Harm Inventory (SHI). The behavioural scales contained in each measure were administered to 568 young Australians aged 18 to 30 years (62% university students, 21% mental health patients, and 17% community members). Scale quality was examined against the stringent standards for unidimensional measurement provided by the Rasch model.

RESULTS

According to the stringent post-hoc tests provided by the Rasch measurement model, there is support for the unidimensionality of the items contained within each of the scales. All six scales contained items with differential item functioning, four scales contained items with local response dependency, and one item was grossly misfitting (due to a lack of discrimination).

CONCLUSIONS

This study supports the use of behavioural scales to measure a DSH construct, justifies the summing of items to form a total DSH score, informs the hierarchy of DSH methods in each scale, and extends the previous evidence for reliability and external validity (as provided by test developers) to a more complete account of scale quality. Given the overall adequacy of all six scales, clinicians and researchers are recommended to select the scale that best matches their adopted definition of DSH.

Motivations for self-injury, affect, and impulsivity: a comparison of individuals with current self-injury to individuals with a history of self-injury

Individuals who report nonsuicidal self-injury (NSSI) are characterized by the tendency to act rashly while experiencing distress (negative urgency), the tendency to act without thinking, and endorsement of both social and affect regulation motives for the behavior. However, very little research has identified characteristics that distinguish current self-injurers from those with a history of the behavior. The purpose of this study was to compare individuals with current self-injury to a history of self-injury on impulsivity-related personality traits, motives for self-injury, and distress. Among a sample of 429 undergraduates, 120 reported self-injury. Among these 120 individuals, 33 endorsed self-injury within the past month, with a mean frequency of 4.77 acts of NSSI. Within the self-injury group, current self-injurers reported higher endorsement of affect regulation motives for NSSI, and higher levels of current negative affect than individuals with a history of self-injury. There were no differences between current and former self-injurers on measures of impulsivity, endorsement of social motives for NSSI, or positive affect. We propose that individuals who use NSSI to regulate negative affect may be more likely to repeatedly engage in this behavior over time.

Co-calibration of deliberate self harm (DSH) behaviours: towards a common measurement metric

The purpose of this study was to co-calibrate items from different deliberate self-harm (DSH) behavioural scales on the same measurement metric and compare cut points and item hierarchy across those scales. Participants included 568 young Australians aged 18-30 years (62% university students, 21% mental health patients, and 17% community volunteers). Six DSH scales (containing 82 items) were administered, namely, Self-Injury Questionnaire Treatment Related (SIQTR), Self-Injurious Thoughts and Behaviours Interview (SITBI), Deliberate Self-Harm Inventory (DSHI), Inventory of Statements About Self-Injury (ISAS), Self-Harm Information Form (SHIF) and Self-Harm Inventory (SHI). Data were co-calibrated onto an underlying metric using the Rasch measurement model. The resulting calibration shows that the different scales occupy different ranges on the hierarchy of DSH methods with prevalence estimates ranging from 47.7 to 77.1%. A raw score conversion table is provided to adjust prevalence rates and to equate cut points on the six scales. A Rasch-validated hierarchy of DSH behaviours is also provided to inform the development of DSH nomenclatures and assist clinical practice.

Skin picking phenomenology and severity comparison

OBJECTIVE

Despite the substantial distress and impairment often associated with skin picking, there currently is only limited research examining various phenomenological aspects of this behavior. The present research contributes to the existing literature by investigating phenomenological variables related to skin picking, such as family involvement, anxiety, depression, and the emotional consequences of skin picking. Moreover, on the basis of symptom severity level, differences were explored between individuals with skin picking who were from a psychiatric population.

METHOD

Forty individuals with various clinician-ascertained DSM-IV diagnoses in addition to skin picking symptomatology participated in the present study, which was conducted from September 2002 through January 2003. Participants were administered a self-report questionnaire (which assessed demographic, symptom, and past diagnostic information) as well as the Beck Depression Inventory, the Beck Anxiety Inventory, and the Self-Injury Interview.

RESULTS

Phenomenological data on various aspects of individuals with skin picking are presented. Individuals with mild skin picking and individuals with severe skin picking were compared and found to differ in the level of distress they experienced (t = -2.35, p = .05) and the amount of damage caused by their picking behavior (t = -3.06, p = .01).

CONCLUSION

Overall, skin picking represents a behavior with its own unique characteristics and accompanying levels of distress and impairment that warrants specific attention by clinicians.

Should nonsuicidal self-injury be a putative obsessive-compulsive-related condition? A critical appraisal

Nonsuicidal self-injury (NSSI) has many behavioral and cognitive features that would make it appear to be closely tied to obsessive-compulsive disorder (OCD). Obsessive-compulsive-related disorders (OCRDs) have been described in the literature as conditions that share a common phenomenology, neurobiology, and treatment response. The authors reviewed the literature describing the degree that NSSI is similar to, and distinct from, OCRDs based on these hypothesized common areas. They conclude with recommendations for conceptualization that draws partly from the OCRD literature and from cognitive-behavioral models of rumination.

A Review of Physical and Mental Health Consequences of Child Abuse and Neglect and Implications for Practice

This article provides an overview of mental and physical health outcomes of child maltreatment to help health care providers identify the consequences of maltreatment and consider treatment options. Child maltreatment is associated with a variety of negative physical and mental health outcomes that affect the individual throughout the lifespan and place a substantial burden on both victims and the population as a whole. The review begins with an overview of the role of physicians in identifying abuse and neglect in the clinic setting. Next, current research findings on physical and mental health outcomes in children, adolescents, and adults are reviewed. Finally, opportunities for primary prevention of abuse and neglect are discussed. Primary prevention strategies can avoid risk for maltreatment, and subsequent interventions for victims have the potential to greatly improve their health.

A systematic literature review: self-mutilation among adolescents as a phenomenon and help for it-what kind of knowledge is lacking?

The aim of this review article is to present current knowledge of self-mutilation among adolescents as a phenomenon and to define what kind of knowledge is lacking based on existing literature. The literature searches were executed in the CINAHL and Medline databases in 2010. The analysed data consisted of 126 articles and inductive content analysis was carried out. Existing knowledge of self-mutilation was categorized into the following two classes: (1) self-mutilation as a phenomenon and (2) caring for persons who self-mutilate or self-harm.

Prevalence and clinical correlates of deliberate self-harm among a community sample of Italian adolescents

The aims of this study were to investigate the rates of deliberate self-harm (DSH) behavior among an Italian adolescent sample, as well as to explore its clinical correlates. On a sample of 234 adolescents in Italian secondary schools (Mean age = 16.47; SD = 1.7) were assessed the DSH as well as externalizing symptoms (including both conduct disorder [CD] and oppositional defiant disorder [ODD] symptoms), borderline personality disorder [BPD] symptoms, dissociative symptoms, and the incidence of life-stressors. Consistent with past research on DSH in youth, 42% of the adolescents in this sample engaged in DSH. Results indicate a positive association between DSH and all psychopathological correlates, including BPD, dissociative, and ODD and CD symptoms. Further, findings revealed an association between DSH and specific life-stressors (i.e., psychological and sexual abuse, natural disasters and serious accidents, the loss of someone important, and the witnessing of family violence or a serious accident).

Deliberate self-harm in Oxford University students, 1993-2005: a descriptive and case-control study

BACKGROUND

Deliberate self-harm (DSH; intentional self-poisoning or self-injury) is a major problem among young people and has been identified as one of the key mental health problems affecting students.

METHOD

Data on DSH presentations to the general hospital in Oxford by Oxford University students were analysed for the 12-year period from 1993 to 2005. The characteristics of the students with DSH were compared with those of age-matched DSH controls in the Oxford City area.

RESULTS

Problems with academic work, relationships with family, partners and friends were most likely to contribute to DSH episodes in students. Many experienced problems with psychiatric disorders and social isolation. The frequency of eating disorders was very high in students, and contributed to DSH significantly more often than in controls. Fewer students than controls self-poisoned in the DSH episode, fewer had personality disorder and fewer had problems with physical health, finance, housing and violence. Alcohol consumption in association with DSH and alcohol-related problems were common in both students and controls. Male students had significantly higher suicide intent than controls. Many students were referred to the university counselling service for follow-up, a resource not available to non-student controls.

CONCLUSIONS

Comparison of university students following DSH with age-matched controls has shown key differences in psychiatric characteristics, problems contributing to DSH and aftercare offered. These findings may help in the design of targeted self-harm prevention and management strategies for students.

Deliberate self-harm and suicide in adolescents

Deliberate self-harm (DSH) is a widespread yet often hidden problem in adolescents and young adults. Though most DSH can be classified as "non-suicidal self-cutting", some do go on to commit suicide. In this paper, deliberate self-harm is examined, including its prevalence, etiology, management, and future research directions using self-cutting and self-burning as examples. This article reviews recent literature to help understand what is known about self-cutting behavior and its potential relationship to suicide as well as provide direction for research. Research shows that different ecological factors at the individual, family, peer, and societal levels are related to deliberate self-harm. Although there is an association between some self-injurers and drug abuse (including alcohol abuse) as well as eating disorders, there are various subgroups of self-cutters and most are not at high risk for suicide. However, all acts of self-injury should be taken seriously by health care professionals and comprehensive therapy offered to any adolescent with a history of DSH. Future research directions on deliberate self-harm are also discussed.

Risk factors and correlates of deliberate self-harm behavior: a systematic review

OBJECTIVE

Deliberate self-harm behavior--without suicidal intent--is a serious health problem and may be studied as a clinical phenomenon in its own right. Empirical studies of sociodemographic and psychological correlates and risk factors are systematically reviewed.

METHODS

We searched Medline, PsycINFO, PSYNDEX (German psychological literature), and reference lists. We targeted self-induced bodily harm without conscious suicidal intent. Studies on suicidal behavior or self-poisoning were only included if they also assessed nonsuicidal self-harm.

RESULTS

Fifty-nine original studies met the criteria. Deliberate self-harm may occur at all ages, yet adolescents and young adults are at a higher risk. Evidence on gender is complex. Only 5 studies realize a prospective design (6 months to 10 years) and test predictors. The majority use cross-sectional and retrospective methods. No longitudinal study (separately) examines new incidence. Evidence of correlates encompasses distal/proximal, person/environment, and state/trait factors. Many studies report associations between current self-harm behavior and a history of childhood sexual abuse. Adolescent and adult self-harmers experience more frequent and more negative emotions, such as anxiety, depression, and aggressiveness, than persons who do not self-harm. Two studies yield specific interactions between childhood trauma and current traits and states such as low emotional expressivity, low self-esteem, and dissociation with respect to a vulnerability to self-harm.

CONCLUSION

Evidence of distal, biographical stressors is fairly strong. Proximal stressors have rarely been investigated; protective factors, hardly at all. Despite many findings of correlates, the data do not yet justify terming them risk factors. Longitudinal studies are needed.

Skin picking behaviors: An examination of the prevalence and severity in a community sample

Body-focused repetitive behaviors such as skin picking have gained recent attention in the psychiatric literature. Prevalence of skin picking has not been well researched and is difficult to estimate; however, consequences of such behaviors can include severe medical complications and impaired social and occupational functioning. Given this, this study examined: (1) the prevalence and severity of skin picking in a nonclinical community sample, and (2) associations between skin picking and other measures of psychological functioning. Three hundred and fifty-four participants completed measures of psychological functioning and skin picking frequency and severity. A total of 62.7% endorsed some form of skin picking and 5.4% reported clinical levels of skin picking and associated distress/impact. Direct associations were found between skin picking and depressive, anxiety, and obsessive-compulsive symptoms, which may support the emotional regulation model of pathological skin picking. To establish proper diagnostic classification of pathological skin picking and optimize treatment planning and outcome, further investigation of functional relationships between skin picking and affective distress is needed.