Self-injurious behavior and mood regulation in borderline patients

Self-Injurious Behavior and Its Characteristics in a Sample of Mexican Adolescent Students

Adolescence is a difficult stage, a period of risk for developing disorders, including depression and self-injurious behavior. A non-random sample was drawn (n = 563) from first-year high school students (32.8%) 185 males and 378 females (67.14%) from public schools in Mexico. The age range was 15 and 19 years, with a mean age of 15.63 (SD = 0.78). According to the results, the sample was divided into n1 = 414 (73.3%) adolescents without self-injury (S.I.) and n2 = 149 (26.4%) S.I. adolescents. In addition, results were obtained on methods, motives, time, and frequency of S.I., and a model was generated in which depression and first sexual experience obtained the highest Odd Ratio and d values in their relationship with S.I. Finally, we contrasted the results with earlier reports and concluded that depression is an important variable in S.I. behavior. Early S.I. detection will prevent the aggravation of S.I. and suicide attempts.

Borderline personality disorder traits and rates of NSSI during the COVID-19 pandemic: An initial investigation

Objective: The current study evaluated frequency of nonsuicidal self-injury (NSSI) and associated maladaptive traits between three time periods: pre-pandemic, early pandemic, and later pandemic. Participants: Two college student samples (n = 362; n = 337) were collected via two online studies. Method: Participants completed measures assessing maladaptive borderline personality traits, engagement in NSSI over the past month, and reasons for and types of NSSI engaged in across the lifetime. Results: Results demonstrated a stable and potentially a slight increase in general rates of NSSI over the course of the pandemic. Further, specific maladaptive traits that underly borderline personality disorder (i.e., despondence, fragility, self-disturbance, and anxious-uncertainty) were related to engagement in NSSI 1-month post COVID. Conclusion: The study highlights the need for added interventions that might reach at risk populations during these heightened periods of stress.

A systematic scoping review of dissociation in borderline personality disorder and implications for research and clinical practice: Exploring the fog

BACKGROUND

Borderline Personality Disorder (BPD) is frequently complicated by the presence of dissociative symptoms. Pathological dissociation is linked with earlier and more severe trauma exposure, emotional dysregulation and worse treatment outcomes in Posttraumatic Stress Disorder and Dissociative Disorders, with implications for BPD.

OBJECTIVE

A systematic scoping review was conducted to assess the extent of current literature regarding the impact of dissociation on BPD and to identify knowledge gaps.

METHODS

Four electronic databases (MEDLINE, APA PsycINFO, EMBASE, CINAHL Plus) were searched, and English peer-reviewed studies with adults with BPD were included, following Preferred Reporting Items for Systematic reviews and Meta-Analysis (PRISMA) extension for scoping reviews (PRISMA-ScR) 2018 guidelines.

RESULTS

Most of the 70 included studies were observational (98%) with first authors from Germany (59%). Overall, dissociation was associated with increased BPD symptom severity, self-harm and reduced psychotherapy treatment response; findings regarding suicide risk were mixed. Dissociation was associated with working memory and cognitive deficits, decreased pain perception, altered body ownership, no substance abuse or the abuse of sedative substances, increased fantasy proneness, personality fragmentation, fearful attachment, dream anxiety, perceived stress and altered stress responses, increased cumulative body mass index, decreased water consumption, several neurological correlates and changes in gene expression.

CONCLUSION

BPD with significant dissociative symptoms may constitute a more severe and at-risk subgroup of BPD patients. However, there are significant research gaps and methodological issues in the area, including the possibility of unrecognized Dissociative Disorders in BPD study populations confounding results. Further studies are needed to better understand the impact of dissociation on BPD course and treatment, and to clarify the most appropriate assessment tools for clinical practice. In addition, interventional studies are needed to develop dissociation-specific BPD treatments to determine whether targeting dissociation in BPD can improve treatment outcomes.

Pain threshold and pain tolerance as a predictor of deliberate self-harm among adolescents and young adults

BACKGROUND

Recently, the assessment of pain has been used as a parameter to differentiate adolescents who indulge in deliberate self-harm from healthy individuals.

AIMS AND OBJECTIVES

The present study was conducted to compare pain sensitivity between three groups, i.e., nonsuicidal self-injury/nonsuicidal self-harm (NSSI), suicide attempters (SA), and matched healthy control (NSSI, SA, and healthy controls).

MATERIALS AND METHODS

Ninety participants (30-NSSI, 30-SA, and 30 matched control) between the age of 10 and 25 years were inducted from the individuals who came for help at the outdoor and emergency services for recent self-harm. Pain sensitivity was assessed by cold pain stimulation test through a cold pressor task.

RESULTS

Pain threshold, pain tolerance, total pain index as well as pain experience intensity were significantly different in the three groups.

CONCLUSION

Participants who indulge in NSSI and SA have significantly higher pain threshold, pain tolerance, total pain index, and pain experience intensity as compared to healthy control. Although all the pain parameters were higher in the NSSI group as compared to SA group, the difference did not reach to significant level.

Predicting engagement in nonsuicidal self-injury (NSSI) over the course of 12 months: the roles of borderline personality disorder pathology and emotional consequences of NSSI

BACKGROUND

Despite theories that negative reinforcement in the form of relief from negative emotions maintains nonsuicidal self-injury (NSSI), no studies have examined the extent to which specific emotional consequences of NSSI predict the maintenance of NSSI over time or explain the greater risk for NSSI found among individuals with borderline personality disorder (BPD) pathology. This study examined whether specific emotional consequences of NSSI relate to the continuance of NSSI behavior over a 12-month period and explain the relation of baseline BPD pathology to future NSSI.

METHODS

Participants with a history of recent repeated NSSI (N = 84) completed baseline measures of BPD pathology, NSSI, and the emotional antecedents and consequences of NSSI, including self-conscious emotions, undifferentiated negative affect, anger, emptiness, sadness, and anxiety; follow-up data on NSSI were collected every three months for one year.

RESULTS

Of the emotional consequences of NSSI examined here, only self-conscious emotions significantly predicted the presence and frequency of NSSI during the 12-month follow-up period. Likewise, whereas BPD pathology was not directly associated with later NSSI, both overall BPD pathology and the specific BPD feature of identity problems were indirectly related to the presence of 12-month NSSI through the greater frequency of post-NSSI self-conscious emotions.

LIMITATIONS

Emotional consequences of NSSI were assessed using a retrospective self-report measure. Only frequency, and not intensity, of emotions before and after NSSI were assessed.

CONCLUSIONS

Results suggest a distinct role of post-NSSI self-conscious emotions in the maintenance of NSSI among individuals with and without BPD pathology.

Is the association of deliberate self-harm with emotional relief stable or dependent on emotional context?

BACKGROUND AND OBJECTIVES

Despite strong support for the role of emotional relief in deliberate self-harm (DSH), no research has examined the impact of emotional distress on the strength of the DSH-relief association. Thus, it remains unclear whether the association of DSH with emotional relief is stable across emotional contexts or context-dependent. This study aimed to examine if the implicit DSH-relief association is stronger in the context of emotional distress (relative to a neutral emotional context).

METHODS

Young adult women with (n = 60) and without (n = 60) a history of recent recurrent DSH were randomly assigned to complete a novel version of the Implicit Association Test (IAT) assessing the DSH-relief association at baseline (following an initial neutral emotion induction) and again following either a neutral or negative (i.e., social rejection) emotion induction.

RESULTS

Consistent with hypotheses, the DSH-relief association was stronger among women with recent recurrent DSH (vs. those without DSH) at baseline. Contrary to hypotheses, however, whereas the DSH-relief association remained stable following both the neutral and negative emotion inductions among participants with DSH, it became stronger across both conditions for participants without DSH.

LIMITATIONS

The use of a community sample of young adult women may limit generalizability to other relevant populations (e.g., clinical populations, young men, adolescents). Additionally, the negative emotion induction may not have been powerful enough to affect the strength of the learned DSH-relief association among individuals with a repeated history of DSH.

CONCLUSIONS

Findings suggest that the repeated use of DSH to bring about emotional relief may engender associations of DSH with relief that are relatively insensitive to emotional context.

Pain-mediated affect regulation is reduced after dialectical behavior therapy in borderline personality disorder: a longitudinal fMRI study

Borderline Personality Disorder (BPD) is characterized by affective instability, but self-injurious behavior appears to have an emotion-regulating effect. We investigated whether pain-mediated affect regulation can be altered at the neural level by residential Dialectical Behavior Therapy (DBT), providing adaptive emotion regulation techniques. Likewise, we investigated whether pain thresholds or the appraisal of pain change after psychotherapy. We investigated 28 patients with BPD undergoing DBT (self-referral), 15 patients with treatment as usual and 23 healthy control subjects at two time points 12 weeks apart. We conducted an fMRI experiment eliciting negative emotions with picture stimuli and induced heat pain to investigate the role of pain in emotion regulation. Additionally, we assessed heat and cold pain thresholds.

At first measurement, patients with BPD showed amygdala deactivation in response to painful stimulation, as well as altered connectivity between left amygdala and dorsal anterior cingulate cortex. These effects were reduced after DBT, as compared with patients with treatment as usual. Pain thresholds did not differ between the patient groups. We replicated the role of pain as a means of affect regulation in BPD, indicated by increased amygdala coupling. For the first time, we could demonstrate that pain-mediated affect regulation can be changed by DBT.

Emotion Dysregulation in the Structure of Self-Injurious Behavior

We present the results of the research of the link between emotion regulation and self-injurious behavior. The sample consisted of 706 respondents aged 14—35 (467 female). Methods: Emotion Dysregulation Questionnaire (Polskaya, Razvaliaeva, 2017), Reasons for Self-Injury Scale (Polskaya, 2017), Coping Behavior Strategies Questionnaire (Vasserman et al., 2008), Psychological Mindedness Scale (Novikova, Kornilova, 2014), Positive and Negative Affect Scale (Osin, 2012). Results: we found out that self-injury is more frequent in females, self-injury risk is most severe at 14—21 years. Significant relationships were yielded for self-injurious behavior, emotion dysregulation, hindered awareness and access to emotions, and coping strategies — confrontation, avoidance, self-control, and responsibility. Regression analysis showed that avoidance as a strategy of emotion dysregulation mediates the influence of negative affect on self-injurious behavior; another form of emotion dysregulation — rumination — predicts the increase of negative and the decrease of positive affect. Conclusions: emotion dysregulation underlies the cycle of negative affect aggravation that leads to self-injury. Adolescence and youth are the most dangerous ages when self-injury is used for negative affect regulation.

Self-Concept Clarity and Emotion Dysregulation in Nonsuicidal Self-Injury

Recent research has linked identity instability with engagement in nonsuicidal self-injury (NSSI; Claes, Luyckx, & Bijttebier, 2014; Claes et al., 2015). This study examined the relationship between self-concept clarity (SCC), an index of identity stability, and NSSI in a sample of 147 college students, using a cross-sectional survey design. The relationship between SCC and emotion dysregulation in NSSI severity was also examined. SCC was significantly negatively associated with NSSI engagement, as well as NSSI frequency and versatility, above negative affect or age. SCC fully accounted for the variance originally explained by emotion dysregulation in NSSI versatility. NSSI frequency was not significantly predicted by emotion regulation, but self-concept clarity reached marginal significance. These findings provide preliminary support for identity instability as a contributing factor to a relationship between emotion dysregulation and NSSI severity. Possible explanations and future research directions are discussed.

Overcoming the oral aspects of -self-mutilation: description of a method

BACKGROUND/AIM

Self-injurious behavior (SIB) is a serious and chronic condition frequently seen in special needs populations, affecting 10% to 17% of individuals diagnosed with intellectual and/or developmental disabilities. A 2.5-year-old infant with SIB, whose presenting symptoms were severe tongue and lip lacerations accompanied by much hemorrhage, is presented here to illustrate the problem and to show how this may be prevented.

MATERIALS AND METHODS

An appliance is described which effectively limits the damage caused by SIB and permits rapid healing of existing injuries.

RESULTS

The method provides for a stable, retentive, and comfortable device on the infant's undererupted and largely nonretentive crowns of the deciduous teeth as well as for all permanent teeth in children, adolescents, and adults.

CONCLUSIONS

The appliance has been successfully employed for the past 10 years in patients with SIB who have attended for treatment in the Special Needs Clinic in our Department.

Exploring the association of deliberate self-harm with emotional relief using a novel Implicit Association Test

Despite the growing consensus that negative reinforcement in the form of emotional relief plays a key role in the maintenance of deliberate self-harm (DSH), most of the research in this area has relied exclusively on self-report measures of the perceived motives for and emotional consequences of DSH. Thus, the primary aim of this study was to extend extant research on the role of emotional relief in DSH by examining the strength of the association of DSH with emotional relief using a novel version of the Implicit Association Test (IAT). The strength of the DSH-relief association among both participants with (vs. without) DSH and self-harming participants with (vs. without) BPD, as well as its associations with relevant clinical constructs (including DSH characteristics, self-reported motives for DSH, BPD pathology, and emotion dysregulation and avoidance) were examined in a community sample of young adults (113 with recent recurrent DSH; 135 without DSH). As hypothesized, results revealed stronger associations between DSH and relief among participants with versus without DSH, as well as among DSH participants with versus without BPD. Moreover, the strength of the DSH-relief association was positively associated with DSH frequency and versatility (both lifetime and at 6-month follow-up), BPD pathology, emotion dysregulation, experiential avoidance, and self-reported emotion relief motives for DSH. Findings provide support for theories emphasizing the role of emotional relief in DSH (particularly among individuals with BPD), as well as the construct validity, predictive utility, and incremental validity (relative to self-reported emotion relief motives) of this IAT.

Levels of dissociation and nonsuicidal self-injury: a quartile risk model

Extant research indicates that dissociation may act as a risk factor for nonsuicidal self-injury (NSSI), but the data are mixed. In this study, 75 university and community females ages 18-35 were assessed for rates of normative, clinical, and severely clinical dissociation as well as for NSSI. Significant differences in normative dissociation were found between the control group and the group reporting a history of NSSI. In addition, normative dissociation--but not clinical or severely clinical dissociation--was found to be significantly associated with NSSI in this sample. Considering this finding in the context of the existing literature, we propose a quartile risk model of dissociation and NSSI as a new approach to the influences of levels of dissociation on NSSI risk.

Pain analgesia among adolescent self-injurers

Although non-suicidal self-injury (NSSI) involves self-inflicted physical harm, many self-injurers report feeling little or no pain during the act. Here we test: (1) whether the pain analgesia effects observed among adult self-injurers are also present among adolescents, and (2) three potential explanatory models proposing that habituation, dissociation, and/or self-criticism help explain the association between NSSI and pain analgesia among adolescents. Participants were 79 adolescents (12-19 years) recruited from the community who took part in a laboratory-based pain study. Results revealed that adolescent self-injurers have a higher pain threshold and greater pain endurance than non-injurers. Statistical mediation models revealed that the habituation and dissociation models were not supported; however, a self-critical style does mediate the association between NSSI and pain analgesia. The present findings extend earlier work by highlighting that a self-critical style may help to explain why self-injurers exhibit pain analgesia. Specifically, the tendency to experience self-critical thoughts in response to stressful events may represent a third variable that increases the likelihood of both NSSI and pain analgesia. Prospective experimental studies are needed to replicate and tease apart the direction of these associations, and may provide valuable leads in the development of effective treatments for this dangerous behavior problem.

Use of the cross-translational model to study self-injurious behavior in human and nonhuman primates

Nonsuicidal self-injurious behavior occurs in the general human population, particularly among teenagers and young adults. Some rhesus macaques also develop self-injurious behavior (SIB) as adolescents or young adults. In both of these cases, the development of harmful behaviors is idiopathic, only coming to the attention of physicians or veterinarians after the disorder is established. Thus, a combination of retrospective, statistical, and empirical procedures are used to understand this disorder. Here, we identify concordances between macaques and humans across five different levels of analysis-(1) form and prevalence, (2) etiology, (3) triggering events, (4) function/maintenance, and (5) therapeutic intervention-and show the value of the cross-translational model (macaques to humans and humans to macaques) in understanding this phenomenon. Substantial concordance is present with respect to the range of severity, the presence of early life stress exposure, and emotional dysregulation. In the macaque model, additional information is available on the hypothalamic-pituitary-adrenal axis stress response system, possible genetic involvement, and the immediate contextual situations that appear to trigger or exacerbate SIB episodes. In contrast, considerably more information is available from human studies on the effectiveness of various treatment regimens. Veterinarians have drawn on this information to explore these therapeutic interventions in monkeys. We expect that models of SIB will continue to have cross-translational impact as scientists and practitioners move from preclinical to clinical research and treatment.

Nonsuicidal self-injury: an emotion regulation perspective

BACKGROUND

Nonsuicidal self-injury (NSSI) is widely thought to serve an emotion-regulatory function.

METHOD

The focus of the present paper is to provide a conceptual framework for understanding how NSSI might modify a person's emotions.

RESULTS

Drawing upon the process model of emotion regulation, we argue that 5 families of emotion regulation strategies may be engaged by NSSI. Individuals may engage in NSSI as an alternative to more distressing situations. They also may use NSSI to modify their social environment. Individuals may shift their attention away from unpleasant emotions or thoughts via NSSI. NSSI may change cognitions about the self via self-punishment or transformation of the self from higher-order to lower-order awareness. NSSI may also bring about various physiological effects, such as changes in endogenous opioids or parasympathetic nervous system activation, as a way of modulating emotional responses.

CONCLUSION

Simply labeling NSSI as 'emotion regulatory' does not tell us precisely what is going on. This is because at any given moment, NSSI can serve to regulate emotions in many different ways. One key challenge is to clarify the precise functions NSSI may be serving for a given individual in a particular context.

Emotion differentiation as a protective factor against nonsuicidal self-injury in borderline personality disorder

Evidence that nonsuicidal self-injury (NSSI) serves a maladaptive emotion regulation function in borderline personality disorder (BPD) has drawn attention to processes that may increase risk for NSSI by exacerbating negative emotion, such as rumination. However, more adaptive forms of emotion processing, including differentiating broad emotional experiences into nuanced emotion categories, might serve as a protective factor against NSSI. Using an experience-sampling diary, the present study tested whether differentiation of negative emotion was associated with lower frequency of NSSI acts and urges in 38 individuals with BPD who reported histories of NSSI. Participants completed a dispositional measure of rumination and a 21-day experience-sampling diary, which yielded an index of negative emotion differentiation and frequency of NSSI acts and urges. A significant rumination by negative emotion differentiation interaction revealed that rumination predicted higher rates of NSSI acts and urges in participants with difficulty differentiating their negative emotions. The results extend research on emotion differentiation into the clinical literature and provide empirical support for clinical theories that suggest emotion identification and labeling underlie strategies for adaptive self-regulation and decreased NSSI risk in BPD.

Effects of suppression and acceptance of sadness on the urge for non-suicidal self-injury and self-punishment

The present study wanted to test the course of the urge for non-suicidal self-injury (UNSSI) and the urge for self-punishment (USP) when suppressing or accepting upcoming emotions in response to a sadness-inducing film clip in female participants with borderline personality disorder (BPD). Thirty-six women with BPD were allocated either to a condition in which they were asked to engage in expressive suppression or acceptance while watching a sadness-inducing film clip. Ratings of UNSSI, USP, and positive and negative emotions were assessed prior to the clip (baseline), immediately after it (t1) and after a 5min waiting period (t2), during which participants viewed landscape pictures. Additionally, physiological measures were obtained. Main results revealed a significant increase in UNSSI from baseline to t2 in the acceptance, but not in the suppression group. Furthermore, USP scores significantly increased from baseline to t2 in the acceptance, but not in the suppression condition. However, there was no differential impact on the sympathetic and parasympathetic branch depending on strategy. The results are in line with recent literature showing that expressive suppression in BPD may also have an adaptive function.

Nonsuicidal Self-Injury, Suicidal Behavior, and Their Co-occurrence as Viewed Through the Lens of the Interpersonal Theory of Suicide

Suicidal and nonsuicidal self-injurious behaviors represent perplexing yet highly prevalent public health problems. Though the behaviors are differentiable, they frequently co-occur. The nature of the association between them, however, remains poorly understood. The interpersonal theory of suicide (Joiner, 2005; Van Orden et al., 2010) offers one viable framework for enhancing our understanding in this domain. In this review, we provide an overview of the literature on nonsuicidal self-injury, its relation to suicidal behavior, and how the interpersonal theory of suicide conceptualizes this relationship. Alternative perspectives and future directions are also discussed.

Relationship of alexithymia and dissociation with severity of borderline personality features in male substance-dependent inpatients

The aim of this study was to evaluate possible interactions between severity of borderline personality features (BPFs), dissociative experiences, and alexithymia among substance-dependent men while controlling for their current age, depression, and anxiety. Participants were 200 substance-dependent men consecutively admitted to a dependency treatment unit. The Borderline Personality Inventory, the Toronto Alexithymia Scale, the Dissociative Experiences Scale, the Beck Depression Inventory, and the Spielberger State-Trait Anxiety Inventory were administered to all participants. Severity of negative affect, alexithymia, dissociative experiences, and BPF were correlated with each other. Being younger, severity of dissociative experiences, difficulty in identifying feelings, depression, and trait anxiety predicted the severity of BPF in linear regression analysis. These findings suggest that alexithymia and dissociative experiences may be a way of coping with depression and chronic anxiety, but they also seem to be related to the severity of BPF independent of the negative affect and from each other.

The relationship between body dysmorphic disorder behaviors and the acquired capability for suicide

In a sample of 200 individuals diagnosed with body dysmorphic disorder (BDD), we utilized the interpersonal-psychological theory for suicide as a framework to examine BDD behaviors that might be associated with suicide risk, insofar as they might increase the acquired capability for suicide. We predicted that physically painful BDD behaviors (e.g., cosmetic surgery, restrictive eating) would be associated with suicide attempts but not suicide-related ideation because these behaviors increase capability for, but not thoughts about, suicide. Our hypothesis was partially confirmed, as BDD-related restrictive food intake was associated with suicide attempts (but not suicide-related ideation) even after controlling for numerous covariates.

Is non-suicidal self-injury an "addiction"? A comparison of craving in substance use and non-suicidal self-injury

There is debate among researchers regarding the most appropriate conceptual model of non-suicidal self-injury (NSSI). Some argue that NSSI is best viewed within an addictions framework. Because craving of substances is a key concept in the addictions literature, we sought to compare the nature of craving in NSSI and substance use. Measures of NSSI, substance use, and craving were administered to a sample of adolescents (n=58) receiving psychiatric treatment. It was found that total craving scores were significantly lower for NSSI than for substances. Item-level analyses suggested that substances are craved in a variety of contexts, whereas NSSI is typically craved in the context of negative emotions. The pattern of results remained the same when analyses were limited to patients who engaged in both NSSI and substance use. Thus, findings appear to be due to differences in the nature of the behaviors themselves rather than to individual differences between those who engage in NSSI or use substances. We conclude that, while both behaviors have powerful reinforcement contingencies, NSSI appears to be almost exclusively maintained by negative reinforcement (e.g., the reduction of aversive emotions). Findings are more consistent with emotion regulation than addiction models of NSSI.

Involvement in bullying and suicide-related behavior at 11 years: a prospective birth cohort study

OBJECTIVE

To study the prospective link between involvement in bullying (bully, victim, bully/victim), and subsequent suicide ideation and suicidal/self-injurious behavior, in preadolescent children in the United Kingdom.

METHOD

A total of 6,043 children in the Avon Longitudinal Study of Parents and Children (ALSPAC) cohort were assessed to ascertain involvement in bullying between 4 and 10 years and suicide related behavior at 11.7 years.

RESULTS

Peer victimization (victim, bully/victim) was significantly associated with suicide ideation and suicidal/self-injurious behavior after adjusting for confounders. Bully/victims were at heightened risk for suicide ideation (odds ratio [OR]; 95% confidence interval [CI]): child report at 8 years (OR = 2.84; CI = 1.81-4.45); child report at 10 years (OR = 3.20; CI = 2.07-4.95); mother report (OR = 2.71; CI = 1.81-4.05); teacher report (OR = 2.79; CI = 1.62-4.81), as were chronic victims: child report (OR = 3.26; CI = 2.24-4.75); mother report (OR = 2.49; CI = 1.64-3.79); teacher report (OR = 5.99; CI = 2.79-12.88). Similarly, bully/victims were at heightened risk for suicidal/self-injurious behavior: child report at 8 years (OR = 2.67; CI = 1.66-4.29); child report at 10 years (OR = 3.34; CI = 2.17-5.15); mother report (OR = 2.09; CI = CI = 1.36-3.20); teacher report (OR = 2.44, CI = 1.39-4.30); as were chronic victims: child report (OR = 4.10; CI = 2.76-6.08); mother report (OR = 1.91; 1.22-2.99); teacher report (OR = 3.26; CI = 1.38-7.68). Pure bullies had increased risk of suicide ideation according to child report at age 8 years (OR = 3.60; CI = 1.46-8.84), suicidal/self-injurious behavior according to child report at age 8 years (OR = 3.02; CI = 1.14-8.02), and teacher report (OR = 1.84; CI = 1.09-3.10).

CONCLUSIONS

Children involved in bullying, in any role, and especially bully/victims and chronic victims, are at increased risk for suicide ideation and suicidal/self-injurious behavior in preadolescence.

Co-Occurring Disorders in the Treatment of Nonsuicidal Self-Injury: An Evidence-Informed Approach

Co-occurring disorders are common among patients who present for treatment with nonsuicidal self-injury (NSSI). Evidence-based approaches specifically designed for the treatment of NSSI are limited, although interest in this area of research is growing. An evidence-informed model for the treatment of NSSI and co-occurring disorders is presented here to stimulate interest in addressing co-occurring disorders in the treatment of NSSI. Case examples are presented to highlight the complexity of treating NSSI and co-occurring disorders and to illustrate a model of treatment at the acute level of care. The case examples also underscore the need for clinical researchers to address co-occurring disorders when developing treatments specifically for NSSI.

The roles of affect dysregulation and positive affect in non-suicidal self-injury

Non-suicidal self-injury (NSSI) is a prevalent behavior, yet little is known about associated affective mechanisms. Research has focused on the role of negative affect in NSSI, with positive affect receiving relatively less attention. This study examined affect dysregulation, emotional reactivity, and the experience of positive and negative affect in NSSI. Path analyses revealed that emotional reactivity predicted positive and negative affect after NSSI. Positive affect, in turn, predicted more lifetime acts of NSSI. The results demonstrate the importance of examining multiple facets of affect regulation, as well as the roles of both negative and positive affect in NSSI.

Non-suicidal self-injury in eating disordered patients: a test of a conceptual model

A theoretical model explaining the high co-occurrence of non-suicidal self-injury (NSSI) in eating disordered populations as resulting from childhood traumatic experiences, low self-esteem, psychopathology, dissociation, and body dissatisfaction was previously proposed but not empirically tested. The current study empirically evaluated the fit of this proposed model within a sample of 422 young adult females (mean age=21.60; S.D.=6.27) consecutively admitted to an inpatient treatment unit for eating disorders. Participants completed a packet of questionnaires within a week of admission. Structural equation modeling procedures showed the model provided a good fit to the data, accounting for 15% of the variance in NSSI. Childhood trauma appears to have an indirect relationship to NSSI that is likely to be expressed via relationships to low self-esteem, psychopathology, body dissatisfaction, and dissociation. It appears that dissociation and body dissatisfaction may be particularly salient factors to consider in both understanding and treating NSSI within an eating disordered population.

Thresholds and tolerance of physical pain among young adults who self-injure

Prevalence rates of nonsuicidal self-injury among college students range from 17% to 38%. Research indicates that individuals with borderline personality disorder who self-injure sometimes report an absence of pain during self-injury. Furthermore, self-injury in the absence of pain has been associated with more frequent suicide attempts. The present study examined pain thresholds and tolerance among 44 college students (11 who engaged in self-injury and 33 who did not). Pain thresholds and tolerance were measured using an algometer pressure device that was used to produce pain in previous laboratory research. Participants who engaged in self-injury had a higher pain tolerance than those who did not. In addition, participants who engaged in self-injury rated the pain as less intense than participants who did not. ANCOVAs revealed that depression was associated with pain rating and pain tolerance.

The affect-regulation function of nonsuicidal self-injury in eating-disordered patients: which affect states are regulated?

This study examines the affect regulation function of different types of nonsuicidal self-injury (NSSI) in 177 female eating-disordered inpatients. Almost 45% of the eating-disordered patients displayed at least 1 type of NSSI. Cutting and scratching were the most common forms of NSSI followed by bruising and burning oneself. For all types of NSSI except bruising, the affect regulation function was most strongly endorsed. Affect states reported to precede and follow NSSI were also examined to determine the particular affect states regulated by NSSI. In general, positively valenced low-arousal affect states increased and negatively valenced high-arousal affect states decreased from before to after NSSI. Finally, affective changes associated with NSSI were related to different NSSI characteristics, indicating that the increase in positive affect after NSSI is significantly related to the frequency of NSSI and the numbers of functions reported for NSSI. Theoretical and treatment implications are discussed.

Non-suicidal self-injurious behavior, endogenous opioids and monoamine neurotransmitters

BACKGROUND

Self-inflicted injury, including cutting or burning, is the most frequent reason for psychiatric visits to medical emergency departments. This behavior, particularly when there is no apparent suicidal intent, is poorly understood from both biological and clinical perspectives.

OBJECTIVE

To examine the role of endogenous opioids and monoamine neurotransmitters in non-suicidal self-injury (NSSI).

METHODS

We compared cerebrospinal fluid (CSF) levels of endogenous opioids, 5 hydroxyindolacetic acid (5-HIAA) and homovanillic acid (HVA) in individuals with a history of repetitive non-suicidal self-injury with a diagnostically-matched group of individuals who had never engaged in non-suicidal self-injury. History of suicidal behavior, demographic background and psychopathology was assessed. All patients were diagnosed with a Cluster B personality disorder (i.e. borderline, antisocial, narcissistic or histrionic) (N=29) and had a history of at least one suicide attempt. Fourteen participants had a history of repeated non-suicidal self-injurious behavior (NSSI) in adulthood and 15 did not (no NSSI).

RESULTS

The NSSI group had significantly lower levels of CSF beta-endorphin and met-enkephalin when compared with the non-NSSI group. CSF dynorphin, HVA and 5-HIAA levels did not differ. Severity of depression, hopelessness and overall psychopathology was greater in the NSSI group.

CONCLUSION

beta-endorphin and met-enkephalin, opioids acting upon receptors involved in mediating stress-induced and physical pain analgesia respectively, are implicated in NSSI. Serotonergic and dopaminergic dysfunctions do not appear to be related to NSSI. Based on our findings, we propose a model of non-suicidal self-injury. Our results suggest that drugs acting on the opioid system warrant exploration as pharmacological treatments for NSSI.

The meaning of self-injury and overdosing amongst women fulfilling the diagnostic criteria for 'borderline personality disorder'

OBJECTIVES

To explore the meanings of self-injury and overdosing, and the relationship of each to the other, for women who have fulfilled the diagnostic criteria for borderline personality disorder.

DESIGN

Four women with a history of both self-injury and overdosing were recruited through a local psychotherapy service and interviewed following a semi-structured framework.

METHODS

The interview transcripts were systematically analysed utilizing interpretative phenomenological analysis.

RESULTS

The analysis lead to the construction of three interrelated themes: (a) The context of distress. Examples were inclusive of temporally distal factors such as childhood abuse and loss, and proximal factors ranging from the interpersonal (e.g., conflict) through to the intra-personal (e.g., negative thoughts relating to self). (b) The progressive management of distress. An overdose was depicted as a last resort once self-injury had become insufficient a means of self-help to manage feelings of desperation and isolation. (c) Ambivalence in relation to death. The clearly stated intention of an overdose was 'to die'. However, both words and (descriptions of) deeds suggested considerable ambivalence in relation to this--overdoses appearing to depict an attempt to resolve unbearable feelings through an unarticulated 'cry for help' rather than suicide completion.

CONCLUSIONS

The overall impression gained was of a group of women in a world of problematic relations (to both self and others) struggling to know how best to attract support and understanding. In discussion, links are made to the literature on reflectivity/reflexivity through Fonagy's notion of 'mentalization'.

The reinforcing properties of repeated deliberate self-harm

The current study tested hypotheses derived from Joiner's (2005) interpersonal theory of suicide, which proposes that deliberate self-harm (DSH) becomes increasingly more reinforcing with repetition. One hundred six participants with a history of DSH completed questionnaires about their emotions and experience of physical pain during their most recent DSH episode. Consistent with prediction, people with more numerous past DSH episodes felt more soothed, more relieved, and calmer following their most recent episode of DSH. Contrary to prediction, greater numbers of past DSH episodes were associated with more intense physical pain during the most recent episode. The findings suggest that the emotion regulation functions of DSH may become more reinforcing with repetition.

The interpersonal dimension of borderline personality disorder: toward a neuropeptide model

Borderline personality disorder is characterized by affective instability, impulsivity, identity diffusion, and interpersonal dysfunction. Perceived rejection and loss often serve as triggers to impulsive, suicidal, and self-injurious behavior, affective reactivity, and angry outbursts, suggesting that the attachment and affiliative system may be implicated in the disorder. Neuropeptides, including the opioids, oxytocin, and vasopressin, serve a crucial role in the regulation of affiliative behaviors and thus may be altered in borderline personality disorder. While clinical data are limited, the authors propose alternative neuropeptide models of borderline personality disorder and review relevant preclinical research supporting the role of altered neuropeptide function in this disorder in the hope of stimulating more basic research and the development of new treatment approaches.

The functions of self-injury in young adults who cut themselves: clarifying the evidence for affect-regulation

The functions of non-suicidal self-injury were examined in 39 young adults with a history of skin-cutting and other self-injurious behaviors including banging, burning, and severe scratching. Consequences, affect-states, and reasons associated with self-injury were assessed by a structured interview. Results indicate that self-injury is associated with improvements in affective valence and decreases in affective arousal. Specifically, participants tended to feel overwhelmed, sad, and frustrated before self-injury, and relieved and calm after self-injury. Further, these affective changes predict lifetime frequency of self-injury, suggesting that they reinforce the behavior. Finally, although reasons for self-injury related to both affect-regulation (e.g., to release emotional pressure that builds up inside of me) and self-punishment (e.g., to express anger at myself) were endorsed by a majority of participants, affect-regulation reasons were overwhelmingly rated as primary and self-punishment reasons as secondary.

Emotional states preceding and following acts of non-suicidal self-injury in bulimia nervosa patients

Bulimia nervosa and non-suicidal self-injury (NSSI) co-occur at high rates, and both have been conceptualized as maladaptive emotion regulation strategies. Treatments focusing on emotion regulation have been designed for both problem behaviors, yet, there exists very little research examining the temporal emotional states surrounding acts of NSSI. Using ecological momentary assessment (EMA) methodology, the current study examined the temporal association between positive and negative emotional states prior to and consequent to acts of NSSI within a subset of bulimia nervosa patients. Results indicate significant increases in negative affect, and decreases in positive affect, prior to an NSSI act. Post-NSSI, positive affect significantly increased while negative affect remained unchanged. The findings offer partial support for an emotion regulation paradigm to understanding NSSI within bulimic populations and implications for treatment are discussed.

Distress and affective dysregulation in patients with borderline personality disorder: a psychophysiological ambulatory monitoring study

Borderline personality disorder (BPD) is characterized by enduring psychological distress and affective dysregulation. Several models have linked both phenomena, but are lacking empirical support. To investigate the relation between psychological distress and components of affective dysregulation (especially inability to label emotions, conflictive emotions, and physiological hyperarousal), we repeatedly assessed these components using a 24-hour ambulatory monitoring approach in a group of 50 BPD patients and 50 healthy controls. Hierarchical linear model analyses identified a clear relation between inability to label emotions and distress in the BPD group (p = 0.0009) but not across all subjects (p = 0.6492). Conflictive emotions were related to psychological distress in both groups (p < 0.0001). This relation is, however, most pertinent to the BPD group who experienced conflicting emotions more frequently. Physiological arousal (heart rate) was related to distress in both groups. Our empirical findings emphasize training in labeling emotions and distress tolerance interventions in treatment for BPD.

Dissociative symptoms are positively related to stress in borderline personality disorder

OBJECTIVE

According to DSM-IV criteria, dissociative symptoms in borderline personality disorder (BPD) occur in response to stress. Empirical evidence is, however, lacking.

METHOD

Using ambulatory monitoring, we assessed dissociative symptoms and subjective ratings of stress every 60 min for 48 h on a palmtop computer in BPD-patients (n = 51), clinical controls (CC; major depression n = 25; panic disorder n = 26), and healthy controls (HC; n = 40). Data analyses were primarily based on hierarchical linear models.

RESULTS

In all groups, states of increased stress were paralleled by increased scores of dissociation, thus confirming the hypothesized association between stress and dissociation. The increase in dissociation was more pronounced in BPD-patients when compared with CC and HC. Additionally, BPD-patients reported heightened dissociative experience compared with CC and HC, even after controlling for stress.

CONCLUSION

Our data suggest that BPD-patients might be prone to dissociation when experiencing stress and are characterized by a generally heightened level of dissociation.

The role of endogenous opioids in the pathophysiology of self-injurious and suicidal behavior

Multiple lines of evidence suggest that endogenous opioids are involved in the pathogenesis of non-suicidal self-injury (NSSI). Evidence for such a role is based on the partial success of opioid antagonist treatment to ameliorate NSSI, reports of altered pain sensitivity during episodes of NSSI, and findings of altered endogenous opioid levels in individuals with NSSI. While suicidal behavior (SB) and NSSI are distinct behaviors, NSSI is a significant risk factor for suicide attempts and suicide. The high co-occurrence of SB and NSSI suggests that they may share a common biology. Available data indicate that endogenous opioids may be involved in the pathophysiology of SB. Future studies of the role of opioids in the biological mechanisms of NSSI and SB are merited and may lead to the development of new treatment modalities.

Testing the emotion regulation hypothesis among self-injuring females: evidence for differences across mood states

Self-injurious behavior (SIB) is frequently motivated to regulate aversive affective states. Research has been limited to group level analyses that often did not adequately differentiate distinct emotions. The present study examined the course of 5 emotional states immediately before, after, and 1 day after SIB among 106 female members of a Dutch support organization. Psychological descriptors suggested that most participants exhibited borderline features. At group level, all negative mood states were highest immediately before, dropped markedly after, and increased again 1 day after SIB, whereas the reverse pattern was observed for vigor. However, at the individual level significant differences between mood states were observed. Effects were most pronounced for tension; two thirds of participants reported a reliable reduction in psychological tension that was still present the next day. SIB should be conceptualized as a maladaptive emotion regulation strategy that is effective in reducing negative affect, in particular psychological tension.

Emotional antecedents and consequences of deliberate self-harm and suicide attempts

Emotional experiences immediately prior to (emotional antecedents) and following (emotional consequences) deliberate self-harm and suicide attempts in female inmates (N = 63) were examined. Anger was the antecedent emotion reported by the largest proportion of individuals who had engaged in deliberate self-harm (45.16%), suicide attempts (40.9%), and ambivalent suicide attempts (30%). Relief and other positive emotional shifts were more common in deliberate self-harm (41.94%) (involving no intent to die) than in suicide attempts or ambivalent suicide attempts, particularly for persons with borderline personality disorder. These findings underscore the utility of discriminating between deliberate self-harm and suicidal behavior and highlight the potential role of anger in triggering such behaviors.

Pain perception in patients with bipolar disorder and schizophrenia

OBJECTIVE

Pain perception is reported to be altered in patients with depression and schizophrenia. However, few studies have investigated the pain perception in patients with bipolar disorders. We therefore aimed to compare pain sensitivity between patients with bipolar disorder, schizophrenia and controls.

METHODS

Study groups consisted of 30 patients with bipolar disorder, and control groups consisted of 27 patients with schizophrenia and 59 healthy subjects. Pain perception was assessed with cold pressor test (CPT) by exposure to ice-water.

RESULTS

Patients with schizophrenia had significantly higher pain thresholds (PTh) than patients with bipolar disorder. There were no differences between the PTh of patients with schizophrenia and healthy control subjects. However, patients with bipolar disorder had significantly lower pain tolerance (PT) in the CPT than patients with schizophrenia and corresponding healthy control subjects.

CONCLUSIONS

The higher PTh in the schizophrenia group compared with the bipolar group found in this study supports further investigation of a potential difference in the pain perception between patients with schizophrenia and bipolar disorder. Theoretical implications of these findings and possible relevant behavioural and neurochemical mechanisms are discussed.

Self-injurious behavior and eating disorders: the extent and nature of the association

We have reviewed the literature on the association between self-injurious behaviors (SIB) and eating disorders from the psychological-behavioral perspective. Our aims were to investigate the extent and possible reasons for the association. A literature search was conducted using the following electronic databases (1989-2005): Medline, PsychInfo and EMBASE. References in identified articles were also screened. The reported occurrence of SIB in eating disorder patients ranged between 25.4% and 55.2%. The figures for occurrence of eating disorders in SIB patients ranged between 54% and 61%. These figures indicate that there is a strong association between these disorders. Impulsivity, obsessive-compulsive characteristics, affect dysregulation, dissociation, self-criticizing cognitive style and need for control were identified as potential factors involved in the association. Early trauma such as childhood sexual abuse and possibly certain characteristics of early family environment might contribute to the development of these factors. We present a hypothetical model which includes these factors and argue that the co-existence of eating disorders and SIB in patients results from several factors being present. SIB and eating disorder symptoms may provide a means whereby patients can deal with each factor simultaneously. The clinical implications of the findings are discussed.

Dissociation and pain perception: an experimental investigation

Dissociative symptoms and abnormalities in pain perception have been associated with a range of disorders. The authors tested whether experimentally induced increases in state dissociation would cause an analgesic response. Participants (N = 120) were randomized to a dissociation induction condition via audiophotic stimulation or a credible control condition and were compared on pre- and postchanges in subjective pain and immersion time in response to a standard cold pressor test. Unexpectedly, the dissociation induction led to small, but significant increases in subjective pain and did not lead to greater immersion time. An exploratory analysis revealed that increases in absorption and derealization significantly predicted increased subjective pain and increased immersion time, respectively.

Suicide Attempt Self-Injury Interview (SASII): development, reliability, and validity of a scale to assess suicide attempts and intentional self-injury

The authors describe the development of the Suicide Attempt Self-Injury Interview (SASII), an instrument designed to assess the factors involved in nonfatal suicide attempts and intentional self-injury. Using 4 cohorts of participants, authors generated SASII items and evaluated them with factor and content analyses and internal consistency statistics. The final measure was assessed for reliability and validity with collateral measures. The SASII assesses variables related to method, lethality and impulsivity of the act, likelihood of rescue, suicide intent or ambivalence and other motivations, consequences, and habitual self-injury. The SASII was found to have very good interrater reliability and adequate validity.

Borderline personality organization and dissociation

The relationship between Kernberg's psychodynamic model of personality organization (PO) and dissociation has not yet been explored. Seventy-two nonclinical subjects and 222 psychiatric patients completed the Dissociative Experiences Scale and the Inventory of Personality Organization. Its Reality Testing subscale emerged as the most important predictor for all facets of dissociation. Discussing our results in the framework of Fonagy and coworkers' model of mentalization, we suggest that dissociation may reflect the preoedipal "pretend" mode of psychic functioning while impaired reality testing and psychotic experiences might be indicative of the "psychic equivalent" mode.

The functions of deliberate self-injury: a review of the evidence

Deliberate self-injury is defined as the intentional, direct injuring of body tissue without suicidal intent. The present article reviews the empirical research on the functions of self-injury. This literature includes self-reports of reasons for self-injuring, descriptions of the phenomenology of self-injury, and laboratory studies examining the effects of self-injury proxies on affect and physiological arousal. Results from 18 studies provide converging evidence for an affect-regulation function. Research indicates that: (a) acute negative affect precedes self-injury, (b) decreased negative affect and relief are present after self-injury, (c) self-injury is most often performed with intent to alleviate negative affect, and (d) negative affect and arousal are reduced by the performance of self-injury proxies in laboratory settings. Studies also provide strong support for a self-punishment function, and modest evidence for anti-dissociation, interpersonal-influence, anti-suicide, sensation-seeking, and interpersonal boundaries functions. The conceptual and empirical relationships among the different functions remain unclear. Future research should address the measurement, co-variation, clinical correlates, and treatment implications of different functions.