Nonsuicidal Self-Injury: Its Associations With Pathological Internet Use and Psychopathology Among Adolescents

A study of the interactive mediating effect of ADHD and NSSI caused by co-disease mechanisms in males and females

Background

Non-suicidal self-injury (NSSI), of which the predisposing factors are complex and diverse, profoundly affects the physical and mental health of young people. Therefore, this work established an NSSI intermediary network model considering the interaction of multiple factors. A mediating effect between attention-deficit/hyperactivity disorder (ADHD) and NSSI, considering the influence of comorbidities, such as depression, anxiety, and impulsive personality, was proposed based on sex differences.

Methods

A total of 2,689 middle school students in Ningbo City, Zhejiang Province, China, were randomly sampled and participated in this study. Data regarding their demographic characteristics, attention deficit, hyperactivity/impulsivity, NSSI, anxiety, depression, internet addiction, and other comorbid symptoms were collected and analyzed. After initially screening the data, variables were assessed for significance using a single-factor inter-group difference analytic method, and a binary logistic regression analysis was performed. The intermediary effect of factors influencing NSSI in males and females was also analyzed.

Results

The overall NSSI rate was 15.16%. The results showed that the impact of individual impulsivity characteristics (impulsiveness, the ADHD with hyperactivity/impulsivity subtype) on NSSI behavior was not significant (regression results, P > 0.05). The degree of association between ADHD with attention deficit and ADHD with comprehension deficit subtypes, and other comorbid symptoms (depression, anxiety, and internet addiction disorder) and NSSI, with odds ratios (ORs) of 7.6/6.42/436.68/3.82/1.86, and 95% bootstrap confidence intervals (CIs) of 4.64, 12.87/3.46, 12.67/137.42, 2659.13/2.32, 6.37/1.31, 2.82, respectively. The results also showed significant effects of ADHD subtypes on comorbid symptoms and the path effects of NSSI (P < 0.01). Among them, the mediating effect was the strongest when anxiety was the mediating variable, and the mediating effect of girls was higher than that of boys.

Conclusion

The results of this work demonstrated the influence of ADHD symptoms on NSSI behavior. Among patients with ADHD, patients with subtypes with obvious attention deficit characteristics were more likely to exhibit NSSI behavior, whereas the hyperactive impulse subtype had no direct impact on NSSI. We conclude that adolescent impulsivity may not be directly related to NSSI behavior and that impulsive characteristics jointly affect NSSI behavior through a series of NSSI comorbid symptoms. Notably, the probability of symptom onset and the degree of comorbidity was significantly higher in girls than in boys of the same age, and girls were more prone to NSSI behavior. These findings provide effective theoretical support for the prevention and treatment of adolescent NSSI behavior.

Problematic internet gaming and non-suicidal self-injury in Chinese adolescents: Moderating and mediating roles of anxiety

INTRODUCTION

Despite consistent reports of the association between problematic internet gaming (PIG) and non-suicidal self-injury (NSSI), an increase in PIG does not necessarily lead to increased NSSI. This apparent paradox indicates the presence of other mediators and moderators in the PIG-NSSI association. This study aimed to investigate the role of anxiety as a potential moderating and mediating factor of the PIG-NSSI association in Chinese adolescents.

METHODS

A cross-sectional study was conducted among 10,479 Chinese adolescents (50.5% male; age range, 9-18 years). Standardized self-report questionnaires were used to assess the severity of PIG, anxiety, and NSSI. Spearman correlation and multiple linear regression were applied to examine the relationships among PIG, anxiety, and NSSI. Both moderating and mediating effects of anxiety were assessed using Hayes' methods.

RESULTS

PIG, anxiety symptoms, and NSSI significantly correlated with one another. Anxiety significantly moderated the relationship between PIG and NSSI [B = 0.002, standard error (SE) = 0.000, p < 0.001], and it partially mediated the PIG-NSSI association [B = 0.017, SE = 0.001, 95% confidence interval (CI) 0.014-0.021]. Social concern and concentration were the two dimensions of anxiety that exerted the strongest mediation effect (B = 0.017, SE = 0.002, 95% CI 0.014-0.020).

CONCLUSIONS

Adolescents with PIG and high anxiety are likely to suffer more severe NSSI and may benefit from interventions to reduce anxiety symptoms.

Substance Use, Internet Risk Behavior, and Depressive Symptoms as Predictors of Self-harm Thoughts in Adolescents: Insights from the 2019 ESPAD Survey in Croatia

Self-harm has become a nonspecific symptom of mental distress that is most prevalent in the adolescent population. Since it is often a hidden problem, it is important to focus on preventing it. This study used the data from the Croatian leg of the European School Survey Project on Alcohol and Other Drugs to assess certain risk factors and possible protective factors for self-harm thoughts among 16-year-olds in Croatia. Using binary logistic regression, we identified that being female, having less family support and less parental knowledge of adolescents' activities, more frequent cannabis use, more compulsive Internet use and more frequent depressive symptoms significantly increased the likelihood of self-harm thoughts in this sample. Identifying factors that lead to thoughts of self-harm may open a potential space for self-harm prevention before those thoughts progress into behavior.

Symptomatic, Alexithymic, and Suicidality-Related Features in Groups of Adolescent Self-Harmers: A Case-Control Study

Non-suicidal self-injury (NSSI) is an increasing phenomenon among both clinical and nonclinical adolescent groups and is associated with several psychopathological symptoms, in addition to being one of the main risk factors for suicidality. Nevertheless, differences between clinical and nonclinical samples of self-harmers in symptom dimensions, alexithymia, suicidality, and NSSI-related variables are still scarcely investigated. The current study aimed to fill this gap by enrolling a sample of Italian girls (age range: 12-19 years) that included 63 self-harmers admitted to mental health outpatient services (clinical group), 44 self-harmers without admission to mental health services (subclinical group), and 231 individuals without an NSSI history (control group). Questionnaires investigating psychopathological symptoms, alexithymia, and NSSI-related variables were administered. The results highlighted that all symptom-related variables and alexithymic traits were more severe in the NSSI groups than in the control group; in particular, self-depreciation, anxiety, psychoticism, and pathological interpersonal relationships were distinguished between the clinical and subclinical groups. Compared to the subclinical group, the clinical group was characterized by higher NSSI frequency, NSSI disclosure, self-punishment as the main reason for engagement in NSSI, and suicidal ideation. These findings were then discussed in terms of clinical practice and primary and secondary prevention in the adolescent population.

Risk factors, theoretical models, and biological mechanisms of nonsuicidal self-injury: a brief review

Nonsuicidal self-injury (NSSI) refers to the direct, deliberate infliction of harm to one's body tissue without the intention to die. The prevalence of NSSI has increased significantly globally in recent years and has become an important public health problem affecting the health of people, especially adolescents. The occurrence of NSSI in adolescents is the result of the interaction of different factors. Many scholars have proposed various theoretical models to explain the mechanism of NSSI behavior based on previous research on the influencing factors of NSSI. Moreover, advances have been made in genetic and neuroimaging mechanisms related to NSSI. Understanding the genetic and neuroimaging mechanisms of NSSI is important for both describing and treating the disorder. This literature review discusses the progress made on the risk factors, theoretical models, and biological mechanisms of NSSI.

Problematic internet use and suicidality and self-injurious behaviors in adolescents: Effects of negative affectivity and social support

BACKGROUND

Problematic internet use (PIU) has been shown to be closely associated with suicidality and self-injurious behavior (SSIB), but the mechanism to help explain this association is understudied. The aim of the present study is to test mediating effects of negative affectivity between PIU and SSIB and whether social support moderates this mediating effect.

METHODS

A sample of 2173 middle and high school students (M_age = 14.66, SD_age = 1.87) in central China were recruited. All participants completed a self-report questionnaire assessing PIU, SSIB, negative affectivity, and social support. Simple mediation analysis and moderated mediation analysis were conducted to examine the roles of negative affectivity and social support in the association between PIU and SSIB.

RESULTS

PIU was positively associated with SSIB, and negative affectivity mediated this association (β = 0.255, Boot 95 % CI: 0.219 to 0.296). The indirect effect of negative affectivity was moderated by social support, with a stronger association between PIU and SSIB for adolescents with lower social support (β = 0.228, Boot 95 % CI: 0.178 to 0.282) than their counterparts (β = 0.098, Boot 95 % CI: 0.068 to 0.133).

LIMITATION

Cross-sectional design with self-report measures.

CONCLUSIONS

PIU is a detrimental risk factor for SSIB, as it is associated with high negative affectivity and increased SSIB, which was more robust for adolescents with lower social support. These results highlight the importance of helping adolescents regulate negative affectivity and improving social support-based preventative interventions to reduce SSIB.

Review: Digital experiences and their impact on the lives of adolescents with pre-existing anxiety, depression, eating and nonsuicidal self-injury conditions - a systematic review

BACKGROUND

Published systematic reviews provide evidence linking positive and negative digital experiences to adolescent mental health. However, these reviews focus on the general public rather than the digital experiences of adolescents with different pre-existing mental health conditions and so may be limited in their clinical relevance. We review publications relating to anxiety, depression, eating disorders and nonsuicidal self-injury to identify common and condition-specific digital experiences and how these may be implicated in the origins and maintenance of these mental health conditions.

METHODS

A systematic literature search using a combination of mental health, digital experience (including social media use), and age of the target population terms was conducted on four databases. Detailed findings from the included studies were summarised using a combination of thematic and narrative methods.

RESULTS

Five qualitative and 21 quantitative studies met the eligibility criteria for inclusion (n = 5021). Nine studies included adolescents with depression, one with eating problems, two with nonsuicidal self-injury and 14 with multiple emotional health conditions. The review identified six themes related to the target populations' digital experiences: (a) social connectivity and peer support; (b) escape and/or distraction; (c) social validation and social comparison; (d) accessing/creation of potentially harmful content; (e) cyberbullying; and (f) difficulties with self-regulation during engagement with digital media.

CONCLUSIONS

Digital practices of adolescents with pre-existing clinical vulnerabilities are complex and encompass a range of positive and negative experiences, which appear to have common elements across different clinical populations. The literature is currently too limited to identify disorder-specific practices, with too few direct or indirect comparisons between conditions.

High-risk group and functional subtypes of non-suicidal self-injury in young adults with mental disorders

BACKGROUND

Identifying high-risk groups of non-suicidal self-injury (NSSI) with multiple risk factors and different functional subtypes contribute to implementing person-centered interventions.

METHODS

We investigated NSSI profiles among a sample of 258 psychiatric inpatients aged 18-25 years. All participants completed well-validated measures of internal personal and external environmental characteristics. One-hundred and ninety patients reported a lifetime history of NSSI and completed an additional NSSI assessment. A k-means cluster analysis was conducted to extract characteristics of risk factors and functional subtypes. Independent sample t-test, analysis of variance and χ ² test were used to test the difference of demographic statistical factors, risk factors and functional scores among groups with different frequency of NSSI.

RESULTS

The clustering of risk factors analyses supported 4-clusters. The proportion of repeat NSSI patients was the highest (67.1%) in the group with unfavorable personal and unfavorable environmental characteristics. Functional subtype clustering analyses supported 5-clusters. Among patients with repeated NSSI, those with depression were mainly accompanied by the "Sensation Seeking" subtype (39.7%), bipolar disorder mainly supported the "Anti-suicide" subtype (37.9%), and eating disorders were mostly "Social Influence" subtype (33.3%). There was an interaction between functional subtypes and mental disorders.

LIMITATIONS

All participants were in treatment in a psychiatric service and the results may not be generalizable to a community sample. The data included retrospective self-report which may be inaccurate due to recall bias.

CONCLUSION

It is necessary to identify high-risk groups of NSSI who with unfavorable personal and environmental characteristics and clinical interventions need to consider the heterogeneity of patients' functional subtypes of NSSI.

Borderline personality traits mediate the relationship between low perceived social support and non-suicidal self-injury in a clinical sample of adolescents

BACKGROUND

Non-suicidal self-injury (NSSI) is a serious public health concern among adolescents, especially in clinical settings. Social support plays a critical role in the onset and maintenance of NSSI in adolescence. NSSI is closely associated with borderline personality disorder (BPD), yet no previous work has analyzed the mediating role of borderline traits in the relationship between perceived social support (PSS) and NSSI. This study aimed to address this gap.

METHODS

Participants were 228 adolescent patients (12 to 18 years old), who completed a clinical interview and self-report measures of BPD-traits, current psychological distress, emotion dysregulation and PSS. They were grouped based on the presence (vs. absence) of NSSI. Univariate and multivariate logistic regression analyses were used to identify risk factors of NSSI, and a mediation analysis was conducted to examine the intermediary role of borderline traits in the relationship between PSS and NSSI.

RESULTS

NSSI was highly prevalent in our sample (58%) and was associated with higher clinical severity. Low PSS predicted NSSI in univariate, but not multivariate regression. Mediation analyses showed that borderline traits fully accounted for the relationship between low PSS and NSSI, even when controlling for current psychological distress and gender.

LIMITATIONS

Cross-sectional design through self-report assessment.

CONCLUSIONS

Findings suggest that adolescents with low PSS are especially vulnerable for developing NSSI due to elevated BPD traits. In clinical settings, interventions aimed to reduce borderline symptoms may be a promising treatment option for adolescents with NSSI and low PSS.

The Relationship Between Alexithymia and Mobile Phone Addiction Among Mainland Chinese Students: A Meta-Analysis

Alexithymia and mobile phone addiction are common phenomena in daily life. Many studies have explored the internal relationship between them based on different theoretical perspectives, but the extent of the exact correlation is still controversial. To address this controversy and clarify the reasons for the divergence, a meta-analysis of 26 articles comprising 23,387 Chinese students was conducted. The results show that alexithymia was highly positively correlated with mobile phone addiction (r = 0.41, 95% CI = [0.37, 0.45]). Furthermore, the relationship was moderated by mobile phone addiction measurement tool and year of publication, with studies using the Mobile Phone Addiction Tendency Scale (MPATS) having higher correlation coefficients than those using the Mobile Phone Addiction Index (MPAI) or other measurement tools. Studies published in 2020-2021 yielded higher correlations than those published in 2014-2016 and 2017-2019. However, the relationship was not moderated by gender, region, or measures of alexithymia. Therefore, our meta-analysis of available published data indicated that alexithymia and mobile phone addiction in Chinese students are not only highly positively correlated but also affected by mobile phone addiction measurement tools and publication year. Longitudinal studies or experimental studies should be strengthened in the future to further establish the direction(s) of causality for the relation between alexithymia and mobile phone addiction.

A retrospective research on non-suicidal self-injurious behaviors among young patients diagnosed with mood disorders

BACKGROUND

Non-suicidal self-injury (NSSI) is an emerging public concern in both clinical and non-clinical settings, especially in the background of the coronavirus disease 2019 (COVID-19) pandemic. Nevertheless, knowledge of NSSI on a certain disease entity in the later stage of the pandemic was scarce.

OBJECTIVE

This study was conducted for the purpose of exploring the current occurrence and characteristics of NSSI in patients diagnosed with mood disorders (MDs) as well as its correlated factors in the later stage of the pandemic.

METHODS

Three hundred and forty-nine eligible subjects (M ± SD, 21.54 ± 7.62) admitted to a mental health center in Wuhan from 11 November 2021 to 31 January 2022 were included in our study. An umbrella questionnaire comprised of demographics, COVID-19-related factors, Yale-Brown Obsessive and Compulsive Scale (Y-BOCS), Pittsburgh Sleep Quality Index-Revised (PSQI-R), Mobile Phone Addiction Index (MPAI), and Ottawa Self-injury Inventory (OSI) was extended to each subject via shared QR code.

RESULTS

Of 349 patients with MDs included, 151 (43.27%) reported NSSI in the recent 1 month, among whom hand, lower arm/wrist, and scalp were the most hurt body parts, and cutting, hitting, and headbanging were the most adopted methods. "Own idea" was the most common origin of NSSI. In the logistic regression model, age bracket, family monthly income, occupation, level of obsessive-compulsive disorder (OCD) symptoms, sleep duration, withdrawal reaction to the mobile phone, and habits of using a mobile phone were independently associated with NSSI.

CONCLUSION

It was revealed by our study that NSSI was quite prevalent among patients with MDs, especially among those students, adolescents, comorbid with OCD symptoms, inadequate sleeping hours, and suffering from withdrawal reaction to mobile phones. Further research on NSSI in various psychiatric disorders and even in non-clinical settings such as the community population was in urgent need since NSSI in China was not rare.

Internet addiction and nonsuicidal self-injury in adolescence: Associations with offline and online social support

OBJECTIVES

Both nonsuicidal self-injury (NSSI) and Internet addiction (IA) are important health issues for adolescents, and social support has been extensively examined as a protective factor for both. This study aims to compare the effect of offline and online social support on IA, and that on NSSI as well.

METHOD

A total of 1911 Chinese adolescents (53.27% females, M_age  = 16.83 ± 0.37) completed self-report questionnaires assessing offline social support, online social support, IA, and NSSI.

RESULTS

The structural equation modeling analysis showed that offline social support was negatively associated with IA and NSSI, while online social support was positively associated with IA and NSSI; IA was positively associated with NSSI. Furthermore, implications for preventions and interventions of IA and NSSI were discussed. The indirect model explained a relatively small variance of NSSI, indicating the possibility of additional factors in the development of NSSI that should be further investigated.

CONCLUSION

This study indicated the differences between offline and online social support, and their different associations with IA and NSSI.

The Association of Nonsuicidal Self-Injury with Quality of Life and Mental Disorders in Clinical Adolescents-A Network Approach

Although earlier research has highlighted that psychiatric disorders significantly impair patients' quality of life (QoL), few studies have examined the relationship between nonsuicidal self-injury (NSSI) and QoL. Our aim was to investigate whether QoL mediates the mental disorder-NSSI relationship, and to study the QoL ratings agreement of self and parents in a clinical population of adolescents. We involved 202 adolescents from Vadaskert Child Psychiatric Hospital and Outpatient Clinic, Budapest, aged 13-18 years. All participants completed the Deliberate Self-Harm Inventory, Inventar zur Erfassung der Lebensqualität bei Kindern und Jugendlichen, and the Mini International Neuropsychiatric Interview Kid. To map the interrelationship between the NSSI, mental disorders, and QoL dimensions, Mixed Graphical Models were estimated. Adolescents with a history of NSSI rated their QoL to be significantly lower than adolescents without NSSI. Self and parents' QoL ratings are closer in the NSSI sample than in the no-NSSI sample. Among all QoL dimensions, only family problems had a direct significant association with NSSI engagement. Our results highlight that, contrary to our hypothesis, the presence of mental disorders mediates the relationship between most QoL dimensions and the occurrence of NSSI. Our results draw attention to the potential causal effect of environmental factors (e.g., peer problems) on mental disorders that, in turn, result in NSSI. The present paper highlights the importance of network modelling in clinical research.

Factors Associated With Non-suicidal Self-Injury in Chinese Adolescents: A Meta-Analysis

Non-suicidal self-injury (NSSI) in adolescents is an increasing public health problem in China. We conducted a meta-analysis of studies on NSSI in Chinese adolescents (between 10 and 19 years) to examine factors associated with NSSI. Twenty-five papers including 30 separate studies with 186,447 participants were included for analysis. The results from a random-effects model showed a weak, but significant overall prediction of NSSI (OR = 1.734). There were significant associations between the following seven factors and NSSI (ranking by the effect sizes, in descending order): adverse life events (OR = 2.284), negative coping style (OR = 2.040), problematic internet use (OR = 2.023), sleep disturbance (OR = 1.734), traumatic experiences (OR = 1.728), problematic parent-child relationship (OR = 1.585), mental health problems (OR = 1.578). Additionally, NSSI sample type moderated these effects. These findings highlight factors significantly associated with NSSI in Chinese adolescents. Parent-child relationship and mental health of the only children and left-behind children in China deserve more attention. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42019123508.