Nonsuicidal Self-​Injury: Advances in Research and Practice 9781315164182, 9781138039070, 9781138039087

Citation preview

Nonsuicidal Self-​I njury

Nonsuicidal Self-​Injury moves beyond the basics to tackle the clinical and ­conceptual complexity of NSSI, with an emphasis on recent advances in both science and practice. Directed towards clinicians, researchers, and others wishing to advance their understanding of NSSI, this volume reviews and synthesizes recent empirical findings that clarify NSSI as a theoretical and clinical condition, as well as the latest efforts to assess, treat, and prevent NSSI. With expertly written chapters by leaders in the field, this is an essential guide to a disorder about which much is still to be known. Jason J. Washburn, PhD, ABPP is an associate professor in the Department of Psychiatry and Behavioral Sciences at the Northwestern University Feinberg School of Medicine, where he is also the Director of Graduate Studies for the MA and PhD programs in Clinical Psychology. For over a decade, he served as the Director of the Center for Evidence-​Based Practice for AMITA Health Alexian Brothers Behavioral Health Hospital, where he oversaw clinical ­outcomes and research associated with the Center for Self-​Injury Recovery.

Nonsuicidal Self-​I njury

Advances in Research and Practice

Edited by Jason J. Washburn

First published 2019 by Routledge 52 Vanderbilt Avenue, New York, NY 10017 and by Routledge 2 Park Square, Milton Park, Abingdon, Oxon, OX14 4RN Routledge is an imprint of the Taylor & Francis Group, an informa business © 2019 Jason J. Washburn The right of Jason J. Washburn to be identified as the author of the editorial material, and of the authors for their individual chapters, has been asserted in accordance with sections 77 and 78 of the Copyright, Designs and Patents Act 1988. All rights reserved. No part of this book may be reprinted or reproduced or utilised in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers. Trademark notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe. Library of Congress Cataloging-​in-​Publication Data Names: Washburn, Jason J., editor. Title: Nonsuicidal self-injury : advances in research and practice / edited by Jason J. Washburn. Description: New York, NY : Routledge, 2019. | Includes bibliographical references and index. Identifiers: LCCN 2018050625 (print) | LCCN 2018051911 (ebook) | ISBN 9781315164182 (eBook) | ISBN 9781138039070 (hardback) | ISBN 9781138039087 (pbk) | ISBN 9781315164182 (ebk) Subjects: LCSH: Self-injurious behavior. | Self-mutilation. Classification: LCC RC569.5.S48 (ebook) | LCC RC569.5.S48 N67 2019 (print) | DDC 616.85/82–dc23 LC record available at https://lccn.loc.gov/2018050625 ISBN: 978-​1-​138-​03907-​0  (hbk) ISBN: 978-​1-​138-​03908-​7  (pbk) ISBN: 978-​1-​315-​16418-​2  (ebk) Typeset in Bembo by Newgen Publishing UK

This volume is dedicated to the thousands of people who suffer from nonsuicidal self-​injury, the clinicians who work tirelessly to help them, and the researchers who strive to better understand and ameliorate this disorder.

Contents

List of Figures and Tables  Author Biographies  Preface  Acknowledgments  List of Abbreviations 

ix x xv xvii xviii

SECTION I

Introduction to Nonsuicidal Self-​Injury 

1

1 Nonsuicidal Self-​Injury: The Basics 

3

Noel C. Slesinger, Nicole A. Hayes, and Jason J. Washburn

2 Nonsuicidal Self-​Injury: Beyond the Basics 

19

Sarah E. Victor and Angelina Yiu SECTION II

Emerging Conceptual and Categorical Issues 

39

3 Pain and Self-​Criticism: A Benefits and Barriers Approach to NSSI 

41

Jill M. Hooley and Kathryn R. Fox

4 The Neurobiology of Nonsuicidal Self-​Injury 

59

Paul L. Plener

5 Diagnostic Classification of Nonsuicidal Self-​Injury  Amy Brausch

71

viii Contents

6 Nonsuicidal Self-​Injury and Compulsive Disorders 

88

Justyna J urska, Vincent Corcoran, and Margaret Andover

7 Nonsuicidal and Suicidal Self-​Injury 

109

Bita Zareian and E. David Klonsky SECTION III

Assessment and Treatment  8 Comprehensive Assessment of Nonsuicidal Self-​Injury 

125 127

Gregory J. Lengel and Denise Styer

9 Emotion Regulation Group Therapy for Nonsuicidal Self-​Injury 

148

Kim L. Gratz, Johan Bjureberg, Hanna Sahlin, and Matthew T. Tull

10 Atypical, Severe Self-​Injury: How to Understand and Treat It  164 Barent W. Walsh

11 Addressing and Responding to Nonsuicidal Self-​Injury in the School Context 

175

Penelope Hasking, Imke Baetens, Elana Bloom, Nancy He ath, Stephen P. Lewis, Elizabeth Lloyd-​R ichardson, and Kealagh Robinson

12 Toward an Understanding of Online Self-​Injury Activity: Review and Recommendations for Researchers and Clinicians 

195

Stephen P. Lewis, Therese E. Kenny, and Tyler R. Pritchard

13 Prevention of Nonsuicidal Self-​Injury 

215

Kaylee P. Kruzan and Janis Whitlock

Index 

240

Figures and Tables

Figure 1.1 Variability of borderline personality symptoms among acute-​care patients with NSSI (n = 1,267) 

11

Tables 1.1 Differences between Nonsuicidal Self-​Injury and Suicidal Self-​Injury 1.2 Methods of Nonsuicidal Self-​Injury in a Clinical Sample of 1,267 patients 9.1 Content of Emotion Regulation Group Therapy Modules 9.2 Content of the ERITA and Associated Parent Program Modules 10.1 Functions for Atypical NSSI Requiring Medical Attention 10.2 Functions for Atypical NSSI of Unusual Body Areas 10.3 Functions of FBI for Nine Individuals 12.1 Recommended Resources for Those Engaging in NSSI and Other Stakeholders 12.2 Questions to Guide Practitioners 13.1 Individual and Social Elements of Existing Prevention Programs

5 6 150 158 168 168 169 201 207 230

Author Biographies

Margaret Andover, PhD. Dr. Andover is an Associate Professor in Psychology at Fordham University, where she examines the treatment of NSSI and suicidal self-​injury, NSSI functions, factors that influence variability within NSSI, physiological processes of NSSI, and methods for assessing NSSI. Imke Baetens, PhD. Dr. Baetens is a professor in the Department of Clinical & Life Span Psychology at Vrije Universiteit Brussel, where she examines the prevention and treatment of NSSI and other emotional and behavioral problems in children and adolescents. Johan Bjureberg, MSc. Mr. Bjureberg is a researcher in the Centre for Psychiatry Research in the Department of Clinical Neuroscience at Karolinska Institutet, where he examines emotional regulation and NSSI, as well as the dissemination of treatments for NSS. Elana Bloom, PhD. Dr. Bloom is a psychologist and coordinator of the Centre of Excellence for Mental Health in the Student Services Department in the Lester B. Pearson School Board. Amy Brausch, PhD. Dr. Brausch is an associate professor at Western Kentucky University, where she examines adolescent and young adult NSSI. Dr. Brausch has a particular interest in the role of the body in NSSI, including body image, body protection, and body attitudes. Dr.  Brausch is also interested in the overlap between NSSI and risk-​taking behaviors (e.g., substance use, disordered eating/​exercise, and self-​asphyxial behaviors). Vincent Corcoran, MA. Mr. Corcoran is a graduate student in Clinical Psychology at Fordham University, where he receives mentorship from Dr. Margaret Andover. Mr. Corcoran’s interests focus on the association of body evaluation/​perception with NSSI, eating disordered behaviors, and medical non-​adherence. Kathryn R. Fox, MA. Ms. Fox is a graduate student at Harvard University, where she receives mentorship from Dr. Jill Hooley. Ms. Fox’s research focuses on understanding and predicting self-​injurious thoughts and behaviors, with

Author Biographies  xi

a particular interest in the associations among self-​criticism, pain, and pain-​ offset relief. Kim L.  Gratz, PhD. Dr.  Gratz is Chair of the Department of Psychology at the University of Toledo, where she examines emotion dysregulation in NSSI, suicide, borderline personality disorder, and other risky behaviors. Dr. Gratz has received numerous awards for her work, including the Young Investigator’s Award of the National Education Alliance for Borderline Personality Disorder (NEA-​BPD) and the Mid-​Career Investigator Award of the North American Society for the Study of Personality Disorders in 2015. Penelope Hasking, PhD. Dr. Hasking is an Associate Professor in the School of Psychology at Curtin University, where she examines NSSI and other high-​r isk behaviors in youth. Dr. Hasking has a specific interest in the progression of NSSI over time and the intersection between NSSI and school communities. Nicole A. Hayes, MS. Ms. Hayes is a doctoral candidate in the PhD program in Clinical Psychology at Northwestern University Feinberg School of Medicine, where she receives mentorship from Dr.  Jason Washburn. Ms. Hayes’ research focuses on eating disorders and NSSI. Nancy Heath, PhD. Dr. Heath is a James McGill Professor in the Department of Educational and Counselling Psychology at McGill University, where she examines resilience and adaptive functioning in NSSI and other at-​r isk populations. Dr. Heath is recipient of the Canadian Committee of Graduate Students in Education’s 2011 Mentorship Award. Jill M. Hooley, PhD. Dr. Hooley is a Professor of Psychology and Head of the Experimental Psychopathology and Clinical Psychology Program at Harvard University, where her research examines the intersection of NSSI and pain, neurobiological and psychophysiological models of NSSI, and psychosocial predictors of relapse in severe psychopathology. Dr.  Hooley is a recipient of the Aaron T.  Beck Award for Excellence in Psychopathology Research and the Joseph Zubin Award for Lifetime Achievement in Psychopathology Research from the Society for Research in Psychopathology. Justyna Jurska, MA. Ms. Jurska is a graduate student in Clinical Psychology at Fordham University, where she receives mentorship from Dr.  Margaret Andover. Ms. Jurska has specific interests in the intra-​and interpersonal risk and protective factors for NSSI and suicide. Therese E. Kenny, MS. Ms. Kenny is a graduate student in the Department of Psychology at the University of Guelph, where she receives mentorship from Dr. Stephen Lewis to study NSSI and e-​mental health. E. David Klonsky, PhD. Dr.  Klonsky is a Professor of Psychology at the University of British Columbia  –​Vancouver, where he examines NSSI,

xii  Author Biographies

suicide, various aspects of emotion, and borderline personality disorder. Dr. Klonsky has received numerous awards for his scholarship, including from the American Psychological Foundation, the Society of Clinical Psychology, and the Association for Psychological Science. Kaylee P. Kruzan, MA. Ms. Kruzan is a PhD student in the Department of Communication at Cornell University, where she receives mentorship from Dr. Janis Whitlock. Ms. Kruzan has research interests in computer-​mediated and interpersonal communication, as well as interventions for NSSI. Gregory J. Lengel, PhD. Dr. Lengel is an Associate Professor of Psychology at Drake University, where he examines NSSI and dimensional models to personality pathology, especially as they apply to clinical assessment and treatment. Stephen P. Lewis, PhD. Dr. Lewis is an Associate Professor Department of Psychology at the University of Guelph, where he examines the intersection of NSSI, the internet, and social media. Dr. Lewis is the current president of the International Society for the Study of Self-​Injury and co-​founder and co-​director of the website Self-​injury Outreach and Support (http://​ sioutreach.org/​). Elizabeth Lloyd-​ Richardson, PhD. Dr.  Lloyd-​Richardson is an Associate Professor of Psychology at the University of Massachusetts Dartmouth and an Adjunct Associate Professor of Psychiatry and Human Behavior at the Warren Alpert Medical School of Brown University, where she examines adolescent health risk behaviors, including NSSI, weight loss, physical activity, and smoking cessation. Paul L. Plener, MD, MHBA. Dr. Plener is the Head of the Department of Child and Adolescent Psychiatry at Medical University Vienna. Dr. Plener’s research focuses on NSSI and suicide in adolescents, with a particular interest in understanding the neurobiology of NSSI. Dr. Plener is the recipient of numerous scholarships and awards, including the Donald J. Cohen Fellowship and the Emminghaus Prize. Tyler R. Pritchard, MA. Mr. Pritchard is a graduate student in the Department of Psychology at the University of Guelph, where he receives mentorship from Dr. Stephen Lewis to study NSSI and e-​mental health. Kealagh Robinson, MS. Ms. Robinson is a PhD student in the School of Psychology at Victoria University of Wellington, where she examines emotion regulation in adolescents. Hanna Sahlin, MSc. Ms. Sahlin is a PhD student in the Centre for Psychiatry Research in the Department of Clinical Neuroscience at Karolinska Institutet, where she examines emotional regulation and NSSI, as well as the dissemination of treatments for NSS.

Author Biographies  xiii

Noel C.  Slesinger, MS. Ms. Slesinger is a doctoral candidate in the PhD program in Clinical Psychology at the Northwestern University Feinberg School of Medicine, where she receives mentorship from Dr. Jason Washburn. Ms. Slesinger’s research focuses on moderators of clinical treatment for NSSI. Denise Styer, PsyD. Dr. Styer has a doctorate in clinical psychology and is a certified Gaia Leadership Coach with extensive experience working with people struggling with NSSI as well as eating disorders, trauma, and suicide. Dr. Styer is the former Clinical Director of the Center for Self-​Injury Recovery at Alexian Brothers Behavioral Health Hospital. Matthew T. Tull, PhD. Dr. Tull is a Professor in the Department of Psychology at the University of Toledo, where he examines emotional regulation in NSSI, anxiety disorders, post​traumatic stress disorder, and substance abuse, as well as the development of treatments for NSSI. Dr. Tull is the awardee of the 2009 Chaim and Bela Danieli Young Professional Award from the International Society for Traumatic Stress Studies, and the 2010 President’s New Researcher Award from the Association for Behavioral and Cognitive Therapies. Sarah E.  Victor, PhD. Dr.  Victor is a postdoctoral fellow at Western Psychiatric Clinic and the University of Pittsburgh School of Medicine. Dr.  Victor completed her PhD in Clinical Psychology at the University of British Columbia  –​Vancouver, under the mentorship of Dr.  E.  David Klonksy. In addition to her research and clinical training at UBC and Western Psych, Dr. Victor completed a summer clinical internship at Alexian Brothers Behavioral Health Hospital. Barent W.  Walsh, PhD. Dr.  Walsh is the former executive director of The Bridge of Central Massachusetts, which provides a range of services to individuals with mental health and developmental challenges. Dr. Walsh has decades of experience working with people suffering from severe NSSI and suicidal thoughts and behaviors. He is the recipient of the Lifetime Achievement Award from the Massachusetts chapter of the National Association of Social Workers. Jason J. Washburn, PhD, ABPP. Dr. Washburn is an Associate Professor in the Department of Psychiatry and Behavioral Sciences at Northwestern University Feinberg School of Medicine, where he is the Director of Graduate Studies for the MA and PhD programs in Clinical Psychology. Dr.  Washburn has also served as the Director of Evidence-​Based Practice for AMITA Health Behavioral Medicine, which includes Alexian Brothers Behavioral Health Hospital, for 12 years. Janis Whitlock, MPH, PhD. Dr.  Whitlock is a Research Scientist in the Bronfenbrenner Center for Translational Research and Director of the Cornell Research Program on Self-​Injury and Recovery, where she examines

xiv  Author Biographies

NSSI in adolescents and young adults, the intersection of social media and mental health, and youth connectedness to schools and communities. Angelina Yiu, PhD. Dr. Yiu is currently a postdoctoral fellowship at Temple University, working with Dr. Eunice Chen in her eating disorders program. Dr. Yiu is a graduate of Simon Fraser University, where she was mentored by Dr.  Alexander Chapman. Dr.  Yiu completed her clinical internship at Northwestern University Feinberg School of Medicine. Bita Zareian, BA, Pharm.D. Ms. Zareian is a graduate student in Clinical Psychology at the University of British Columbia –​Vancouver, where she receives mentorship from Dr. Frances Chen. Ms. Zareian’s research examines the social and biological factors, such as hormonal contraceptives, contributing to the development and maintenance of depression.

Preface

In 2006, I toured the inpatient, partial hospitalization, and intensive outpatient treatments programs at Alexian Brothers Behavioral Health Hospital (ABBHH) in the northwest suburbs of Chicago. The treatment programs were impressive, particularly the number of patients receiving treatment in highly specialized programs. The sheer number of specialized programs was daunting, providing specialty care for young children to older adults, and conditions from depression to schizophrenia. I then toured the Self-​Injury Recovery Services (SIRS) at ABBHH. Having only recently completed training in Dialectical Behavior Therapy as part of my clinical internship training at the University of Washington School of Medicine, I assumed that this was a service for adults suffering from borderline personality disorder. When I looked in on one of the SIRS sessions at ABBHH, however, I noticed the group was composed almost exclusively of adolescents and emerging adults. I  immediately thought of a patient  –​more accurately, an adjudicated juvenile resident  –​from my clinical internship. At the time, I  was part of a clinical team that assisted administrators and staff of residential facilities managed by the Washington State Juvenile Rehabilitation Administration with program development and behavioral management strategies. In the process of consulting on the intensive behavioral management of a specific juvenile resident, I found myself dumbstruck when seeing this youth for the first time, specifically the scars covering nearly every inch of the resident’s exposed skin. This memory, my first introduction to nonsuicidal self-​injury (NSSI), came back to me in a flood after touring the SIRS program at ABBHH. Immediately after going home that night, I  searched the scientific literature and began to learn more about NSSI. Back in 2006, the literature was still dominated by self-​ injurious behavior among individuals with developmental delays and intellectual disabilities, or “parasuicide” in the context of borderline personality disorder. Among the limited number of articles focused on what we now refer to as NSSI, certain names popped out at me, such as Laurence Claes, Kim Gratz, Nancy Heath, E. David Klonksy, Elizabeth Lloyd-​Richardson, Jennifer Muehlenkamp, Matthew Nock, Mitch Prinstein, Barent Walsh, and Janis Whitlock. Unbeknownst to me, the same year that I  personally “re-​ discovered” NSSI while touring

xvi Preface

ABBHH, many of these soon-​to-​be legends in the field of NSSI met for the first time in 2006 at the invitation of Janis Whitlock. The “Cornell meeting” eventually culminated in the creation of the International Society for the Study of Self-​Injury (ISSS; https:/​itriples.org). In 2008, I found myself invited to attend the second official ISSS conference, hosted by Matthew Nock at Harvard, where my colleagues and I presented some of our first data on outcomes of acute-​care treatment for NSSI. During that and subsequent ISSS conferences, I  came to meet all these legends and their protégés. Many of these folks have come to be my colleagues and friends. Many of them are contributors to this book, and despite my attempts, not all were able to contribute. I am honored and humbled by their incredible body of research and their devotion to this understudied, underidentified, undertreated, and often misunderstood disorder. My tour in 2006 was part of my orientation as a new hire at ABBHH, a part-​time position I took along with my faculty appointment at Northwestern University Feinberg School of Medicine. My position at ABBHH was created to answer a simple yet challenging question that their chief operating officer posed to me: “How well do our treatments work?”To answer this question, I developed a clinical outcome system that was integrated into routine treatment at ABBHH. In developing the system, I  always preferenced measures found to be reliable and valid in the literature. At the time, however, few measures were available for NSSI, especially measures sensitive to change over time. Creating clinically useful measures of NSSI allowed me to enter the academic world of NSSI, with our first publication on this topic in 2010. As time progressed, our clinical outcome databases grew, allowing us to dive further into the data to answer clinically relevant questions about NSSI. Although the quality of the practice-​based research emanating from my team at Northwestern and ABBHH pales in comparison to the rigorous and productive work of the other contributors to this volume, our work typifies my goal, and the subsequent goal of this volume: to inform our clinical services with current clinical science, and to inform clinical science with our clinical services. To achieve this goal, this volume includes chapters that are heavy on research, chapters heavy on clinical practice, and chapters that integrate science and practice. I  am honored that you are reading these contributions, and I can only hope that you integrate what you learn into your own work to improve the lives of people who suffer from NSSI.

Acknowledgments

For Chapter 10, Dr. Walsh acknowledges Julia Chapman, BA (Cornell Research Program on Self-​Injury and Recovery) and Nicole A. Hayes, MS (Northwestern University Feinberg School of Medicine) for their contribution to the literature review. For Chapter  11, we gratefully acknowledge the support of the FWO to Dr. Baetens (12M5915N).

Abbreviations

ABASI ABBHH ABUSI ACC ACE ACT APA APD BDD BFRBs BIP BPD CBT CEM-​NSSI

Alexian Brothers Assessment of Self-​Injury Alexian Brothers Behavioral Health Hospital Alexian Brothers Urge to Self-​Injure Scale anterior cingulate cortex adverse childhood experiences acceptance and commitment therapy American Psychiatric Association avoidant personality disorder body dysmorphic disorder body-​focused repetitive behaviors Barninternetprojektet (Child Internet Project) borderline personality disorder cognitive behavioral therapy Cognitive-​Emotional Model for Nonsuicidal Self-​Injury COMT catechol-​ O-​methyl transferase CR cognitive restructuring dACC dorsal anterior cingulate cortex DBT dialectical behavior therapy DBT STEPS-​A Dialectical Behavioral Therapy Skill Training for Emotional Problem Solving for Adolescents DC decoupling DSHI deliberate self-​harm inventory DSM Diagnostic and Statistical Manual of Mental Disorders ED eating disorder EDB eating disorder behaviors EMA ecological momentary assessment ERGT emotion regulation group therapy ERITA emotion regulation individual therapy for adolescents

newgenprepdf

Abbreviations xix

FASM FBI GERD HD HPA HRT ICBT IMR ISAS ISSS MFY

functional assessment of self-​mutilative behavior foreign body ingestion gastro-​esophageal reflux disease hoarding disorder hypothalamic–​pituitary–​adrenal habit reversal training internet-​based cognitive behavioral therapy illness, management and recovery Inventory of Statements About Self-​Injury International Society for the Study of Self-​Injury Making Friends with Yourself: A Mindful Self-​Compassion Program for Teens MI motivational interviewing MRI magnetic resonance imaging NSIP National Self-​Injury Project NSSI nonsuicidal self-​injury NSSID NSSI disorder NSSIDS NSSID scale OCD obsessive compulsive disorder OCRDs obsessive-​compulsive and related disorders ORI Oregon Resiliency Initiative OSI Ottawa Self-​Injury Inventory PTSD post​traumatic stress disorder RCTs randomized controlled trials SASII Suicide Attempt Self-​Injury Interview SES socioeconomic status SHBQ Self-​Harm Behavior Questionnaire SHI Self-​Harm Inventory SIQ Self-​Injury Questionnaire SIRS Self-​Injury Recovery Services SITBI Self-​Injurious Thoughts and Behaviors Interview SMHP school mental health professional SOS Sources of Strength SOSI Signs of Self-​Injury Program SPD skin picking disorder (excoriation) SSRI selective serotonin reuptake inhibitor TTM trichotillomania

Section I

Introduction to Nonsuicidal Self-​I njury

Chapter 1

Nonsuicidal Self-​I njury The Basics Noel C. Slesinger, Nicole A. Hayes, and Jason J. Washburn

Introduction Nonsuicidal self-​injury (NSSI) is a topic that has gained significant interest around the world, as evidenced by growing coverage in the news, social media, and the entertainment industry (e.g., 13 Reasons Why; Purlington & Whitlock, 2010). Despite this growing interest in NSSI, it is commonly misunderstood by the public, as well as clinicians and researchers. Misunderstanding of NSSI is understandable given that the science of NSSI is in its infancy. The last decade has witnessed a surge of clinical and scientific interest in NSSI and much more is now known than ever before. Yet much remains to be discovered, especially given that much of the research over the last decade has raised more questions than it has answered.This chapter provides an overview of what is now generally well-​accepted knowledge about NSSI, providing an opportunity to address the most commonly misunderstood features of NSSI.

Definition of NSSI The most fundamental misunderstanding of NSSI is what is meant by the term, “NSSI”. The International Society for the Study of Self-​Injury (ISSS) defines NSSI as “the deliberate, self-​inflicted destruction of body tissue that is not socially sanctioned and without suicidal intent” (ISSS, 2018). The specific components of this definition are worth unpacking. First, unsurprisingly, NSSI is a purposeful behavior enacted by the individual that is being injured; it is not accidental and not done by another person. Second, NSSI involves damage directly to human tissue, including soft (e.g., skin) and hard (e.g., bone) tissue. Requiring tissue damage in the definition of NSSI is critical because it excludes from NSSI a broader range of self-​destructive behaviors that are often confused with NSSI, but do not involve immediate tissue damage, such as eating disordered behavior, substance abuse, or reckless behavior (St. Germain & Hooley, 2012). Third, NSSI does not include self-​inflicted injuries that are engaged in for purposes of beautification or for religious or culturally significant reasons, such as tattoos,

4  Noel C. Slesinger et al.

piercings, or other forms of body art or modification (Favazza, 1998). Finally, this definition makes a clear distinction between self-​injury that is engaged in for purposes of ending one’s life (i.e., suicidal self-​injury), and self-​injury for other reasons (i.e., NSSI). The definition of NSSI has not always been clear. Historically, clinicians and researchers struggled with differentiating NSSI and suicidal self-​injury (SSI). The first recorded differentiation of NSSI from SSI appeared in the records and writings of psychiatrists in British asylums in the mid-​1800s (Angelotta, 2015). Discussion of NSSI continued to be found in various writings in the psychoanalytic literature into the early 1900s, culminating with Karl Menninger bringing a popular spotlight to NSSI in his book, Man Against Himself (Menninger, 1938). The foundations for the current definition of NSSI began to be described in the mid to late part of the twentieth century, typically through portrayals of a prototypic “cutter” (Angelotta, 2015). In a seminal paper in 1965, Neil Kessel from Manchester University introduced the phrase deliberate self-​injury, arguing that the label of suicide attempt may be misapplied to a subset of patients for whom their self-​injury “demonstrated some purposefulness, but this purpose was to alter their life situation, not to die” (Kessel, 1965). Not all clinicians or academics accepted Kessel’s proposal. Norman Kreitman and his colleagues from the Royal Edinburgh Hospital acknowledged the diversity of motives involved in self-​injury; however, they proposed the term parasuicide to reflect their perception that NSSI “simulates or mimics suicide” (Kreitman, Philip, Greer, & Bagley, 1969).Years later, H. Gethin Morgan and colleagues from the University of Bristol argued against the term parasuicide because it implied that self-​injury closely resembles suicide. To address this concern, they modified Kessel’s initial phrase from deliberate self-​injury to deliberate self-​harm to reflect behaviors that may not result in actual injury (e.g., drug overdose) (Morgan, Burns-​Cox, Pocock, & Pottle, 1975). Over the last several decades, numerous additional terms have been used to describe what we now consider to be NSSI, including self-​mutilation, self-​ inflicted injury, self-​directed violence, self-​destructive behavior, self-​abuse, suicide gesture, or suicide-​related behavior (Angelotta, 2015). Although most of these terms have fallen out of favor, deliberate self-​harm remains in use, with over 400 references to this term in academic journals in the last decade. Although some researchers continue to use deliberate self-​harm interchangeably with NSSI, most current references to deliberate self-​harm present a conundrum for clinicians and research as they conflate NSSI and SSI. There is now consensus that NSSI and SSI are separate phenomena. As shown in Table 1.1, nonsuicidal and suicidal self-​injury demonstrate marked differences in the method and severity of injury, the function of the injury, and the immediate outcome of the injury (Kerr, Muehlenkamp, & Turner, 2010; Mars et al., 2014). As such, the somewhat cumbersome term of NSSI is now generally accepted as the most accurate description of self-​injury that is for reasons other than a desire to end one’s life.

Nonsuicidal Self-Injury: The Basics  5

Table 1.1 Differences between Nonsuicidal Self-​Injury and Suicidal Self-​Injury

Severity of injury Function of behavior Method of injury

SSI

NSSI

Severe; potentially life-​threatening To die; to sleep and not awaken; to end the pain; to escape or get away Gunshots, hanging, overdose, self-​poisoning, jumping, deep cutting Increases negative affect

Mild, moderate; not potentially life-​threatening To cope; to persist and continue on; to feel better; to stay alive Shallow cutting, scratching skin, burning, banging head/​limbs

Immediate outcome Frequency of injury Infrequent

Decreases negative affect; improves positive affect Frequent

NSSI Methods Another common misunderstanding of NSSI is the assumption that it exclusively involves cutting of the skin. This misunderstanding is reflected in the common labeling of people who engage in NSSI as “cutters,” which originated from references in the clinical and popular literature (Angelotta, 2015). This unfortunate term still exists in the literature (Gregory & Mustata, 2012), despite attempts to remove it from our vernacular (Washburn, 2014). The term is unfortunate not only because it uses a pejorative term that assigns a behavior as an individual’s identity, but also because it is inaccurate. Although it is well established that the most common method of NSSI is cutting or severe scratching of the skin (Klonsky, 2011), cutting is not the only method employed by people who engage in NSSI. Table 1.2 provides a list of the most common forms of NSSI endorsed among one of our samples of patients (n  =  1267) seeking inpatient, partial hospitalization, or intensive outpatient treatment for NSSI. Consistent with findings from community samples (Robertson, Miskey, Mitchell, & Nelson-​Gray, 2013), these patients report engaging in an average of 3.8 (SD = 2.9) different NSSI methods in the year prior to admission. These data clearly demonstrate that NSSI is not accurately represented by the term “cutter” or by assuming that cutting is the only method used. Attempts have been made to differentiate severe from minor NSSI methods. For example, using principle components analysis, NSSI methods such as cutting, carving, scraping, rubbing, burning, and tattooing, were identified as “moderate/​severe” methods, whereas hitting self, self-​biting, inserting or embedding objects, opening up wounds, and drawing blood were identified as “minor” methods (Lloyd-​ Richardson, Perrine, Dierker, & Kelley, 2007). Differentiating severity by specific NSSI methods, however, is challenging because most methods can be carried out in ways that result in minimal injury, or severe injury. For example, in our sample of acute-​care patients (n = 1267),

6  Noel C. Slesinger et al. Table 1.2 Methods of Nonsuicidal Self-​Injury in a Clinical Sample of 1,267 patients NSI Behaviors

Cut skin Scratched skin Hit self Carved skin for pain/​ harm Banged head Prevented healing of injuries Burned skin Drawn blood Tattooed for pain/​ harm Inserted/​embedded objects Gouged skin Broke limbs

%

Days past year

Times per day

Age of onset

Mean (SD)

Mean (SD)

Mean (SD)

91.2 54.2 30.5 29.9

42.2 23.1 9.7 5.0

(69.6) (62.8) (37.5) (24.3)

3.2 3.1 3.1 1.7

(6.6) (6.2) (4.7) (3.9)

13.5 13.4 13.6 13.7

(3.5) (3.6) (4.5) (3.5)

25.0 23.9

7.0 10.9

(33.7) (44.1)

3.2 3.3

(5.6) (6.7)

13.7 13.1

(4.1) (2.9)

21.6 11.7 8.4

2.4 6.5 0.6

(13.5) (34.7) (10.4)

1.4 2.1 1.8

(1.2) (2.3) (5.0)

14.6 12.9 14.7

(8.7) (3.3) (4.3)

5.6

1.2

(15.3)

2.3

(2.5)

12.9

(3.2)

2.3 1.1

0.6 0.3

(10.9) (10.3)

1.7 1.4

(1.3) (1.1)

12.9 12.9

(4.1) (5.5)

among those who reported engaging in cutting their skin, which is considered a moderate-​to-​severe form of NSSI, only 4.3% rated that behavior as resulting in damage requiring medical attention; in contrast, among patients who reported inserting or embedding objects, a “minor” method, 9.3% reported requiring medical assistance. Rather than examining severity by the specific type of method, substantial support is found for the association between severity and the versatility of NSSI methods. For instance, a greater number of NSSI methods has been associated with more frequent engagement in NSSI, earlier age of NSSI onset, greater suicide risk, and likelihood of persisting with NSSI over time (Ammerman, Jacobucci, Kleiman, Uyeji, & McCloskey, 2018; Ammerman, Jacobucci, & McCloskey, 2018; Kiekens et al., 2017; Turner, Layden, Butler, & Chapman, 2013).

Epidemiology of NSSI NSSI, as a discrete behavior over the course of one’s lifetime, is relatively common. Several studies have found lifetime prevalence rates of NSSI to be as high as 46.5% among adolescents and 38.9% among college students (Cerutti, Presaghi, Manca, & Gratz, 2012; Lloyd-​Richardson et  al., 2007). In contrast, other studies have found very low rates of NSSI, for example, as low as 3% among adults (Plener et  al., 2016). The substantial variation in rates across studies and samples is likely due to varying definitions of NSSI and inconsistent methodology. For example, studies have found lower rates of NSSI

Nonsuicidal Self-Injury: The Basics  7

when assessed through a single question (e.g., “Have you injured yourself in the last year?”) versus a checklist of self-​injury behaviors (“Indicate which of the following ways you have injured yourself in the last year”) (Muehlenkamp, Claes, Havertape, & Plener, 2012). To even out many of these methodologic issues in the literature, Muehlenkamp and colleagues identified a lifetime rate of 18% when averaging across 27 studies (Muehlenkamp et al., 2012). This rate, however, reflects individuals who have engaged in NSSI at least once in their life, and is less informative in understanding the rate of individuals with clinically relevant NSSI. For example, a study using a random-​digit dialing sample of adults found a lifetime prevalence of 5.9% for any NSSI, but only 2.7% for repeated (5+) NSSI (Klonsky, 2011). Even more dramatic was a large study of 7,126 high-​school students, of which 24.5% endorsed lifetime NSSI; however, when asked about frequent NSSI, the rate dropped to 5.2% (Sornberger, Heath,Toste, & McLouth, 2012). Given these data, while rates of any lifetime NSSI is high, the number of individuals requiring intervention for their NSSI is likely to be substantially lower. In populations already receiving treatment, rates of NSSI are higher, with rates typically reported between 40% and 60% on inpatient units (Claes, Vandereycken, & Vertommen, 2007; Kaess et al., 2013). While other differences in rates of NSSI have been explored in the literature, few consistent results have been found. For example, no consistent pattern of differences across countries has been found (Muehlenkamp et al., 2012), although many countries have yet to be studied. Differences in prevalence rates by gender are also unclear, with some studies finding no significant differences (Bresin & Schoenleber, 2015; Jacobson & Gould, 2007; Kirkcaldy, Richardson-​Vejlgaard, & Siefen, 2009); however, gender differences appear more pronounced in clinical samples (Bresin & Schoenleber, 2015). For example, in a large acute-​care treatment sample, women comprised 90% of the sample (Washburn, Potthoff, Juzwin, & Styer, 2015). A common epidemiologic question, particularly among clinicians, is if rates of NSSI have increased over the last several decades. Unfortunately, no clear evidence exists to answer this question. NSSI has not been included in long-​ term risk surveillance surveys, as is commonly found for suicidal thoughts and behaviors. Comparisons of cross-​sectional studies of adolescents to adults indicate rates are three times higher among adolescents (e.g., Klonsky, 2011), suggesting a cohort effect of increasing rates. A recent study provides more convincing evidence that rates of NSSI have increased (Wester, Trepal, & King, 2017). This study examined lifetime and current NSSI across three separate cohorts of freshman college students in 2008 (N = 410), 2011 (N = 277), and 2015 (N  =  262). Results indicate a linear increase in self-​reported NSSI for both lifetime (2008 = 16.0%; 2011 = 28.0%; 2015 = 45.0%) and past 90-​day (2008 = 2.6%; 2011 = 12.6%; 2015 = 19.5%) rates. Although limited to just one university, this study provides some support for the argument that NSSI is more common now than in the past.

8  Noel C. Slesinger et al.

Functions of NSSI For the last several decades, clinicians, researchers, and theorists have grappled with why people engage in self-​injurious behavior when they do not have an intent to die. Substantial and converging evidence across different samples, methods, and measures indicate that NSSI is functional; that is, people have identifiable reasons or motivates for engaging in NSSI (Klonsky, 2007). Although numerous functions of NSSI were proposed in the late 1980s and 1990s, the first empirical model of the functions of NSSI to be widely accepted was proposed by Nock and Prinstein in 2004. Based on data from a self-​report assessment of NSSI functions, their four-​function model of NSSI proposed that people engage in NSSI to reduce unpleasant internal experiences (Automatic-​Negative function), to produce desirable internal experiences (Automatic-​Positive function), to avoid unpleasant interpersonal experiences (Social-​Negative function), and to produce desirable interpersonal experiences (Social-​Positive function) (Nock & Prinstein, 2004). Additional research supports a more parsimonious model in which NSSI functions can be factored down to two superordinate functions: Internal or Intrapersonal functions and Social or Interpersonal functions (Klonsky, Glenn, Styer, Olino, & Washburn, 2015). Our sample of acute-​care patients (n = 1,267) demonstrates the dominance of the Internal or Intrapersonal function over the Social or Interpersonal functions:  using a short form of the Inventory of Statements About Self-​Injury, patients endorse Internal or Intrapersonal functions at a rate three times that of Social or Interpersonal functions (2.32 vs. 0.72), a finding replicated seemingly without exception in the literature (Klonsky, 2007; You et al., 2018). More specifically, the affective regulation function is endorsed at the highest rate (3.18), followed by self-​punishment (2.79), anti-​dissociation (2.32), marking distress (1.80), and anti-​suicide (1.54). The centrality of affective regulation in NSSI has also been demonstrated through numerous experimental studies. Using guided imagery and acute pain tasks, these studies have shown elevated negative affect and physiological arousal proceeding NSSI, and subsequent decreases in negative affect and arousal after engaging in NSSI (Hamza & Willoughby, 2015). Consistent with these laboratory approaches, studies using daily diary and ecological momentary assessment methodologies have also found an elevation of negative affect before NSSI or preceding the development of an urge to engage in NSSI (Andrewes, Hulbert, Cotton, Betts, & Chanen, 2017a; Hamza & Willoughby, 2015). For example, a diverse sample of 47 adolescents and emerging adults with NSSI completed assessments on a mobile app five times a day for two weeks (Kranzler et  al., 2018). Increases in negative emotion preceded and predicted engagement in NSSI, and after engaging in NSSI, negative emotions decreased, and positive emotions increased. In addition to optimizing emotional experience through reducing negative affect, at least one study has shown that NSSI can serve a stabilizing function by reducing affective variability (Vansteelandt et al., 2017). In a sample of 32 adults

Nonsuicidal Self-Injury: The Basics  9

with BPD that were assessed ten times a day for eight days, a greater frequency of NSSI was associated with less within-​subject affective variability. In other words, NSSI may not only be maintained through negative reinforcement associated with the reduction of negative affect, but also by stabilizing mood lability. The association between NSSI and affective regulation, however, is likely to be more complex than is suggested by simply indicating that NSSI “regulates affect.” NSSI may regulate affect through different mechanisms or strategies depending on the individual and the context. For example, NSSI may regulate affect by serving as an alternative or distraction to an aversive experience or situation, by changing the social environment, by changing thought process, or by changing physiology via endogenous opioids or the parasympathetic nervous system (McKenzie & Gross, 2014). Further, not all individuals who engage in NSSI experience improved affect or emotional relief. For example, in a study of 30 inpatients with high levels of BPD, NSSI was not associated with an increase in positive emotion, and instead was associated with an increase in negative emotion (Houben et al., 2017). This study suggests that the affective relief associated with NSSI may only be fleeting. Consistent with clinical observations that chronic NSSI is associated with greater severity of NSSI (Washburn, Styer, Gebhardt, & Aldridge, 2013), this study raises the possibility that repetition or escalation of NSSI may be required to obtain the same benefit of NSSI over time. It also important to acknowledge, however, that affective regulation is not the only function of NSSI.As demonstrated previously, self-​punishment, anti-​suicide, anti-​dissociation, and marking distress are also commonly endorsed functions of NSSI. It is also common for individuals with NSSI to endorse multiple functions at the same time. Using our acute-​care sample (n = 1,267), patients endorse an average of 3.0 (SD = 1.9) functions of NSSI as being at least somewhat relevant to their NSSI. These findings remind us that NSSI can serve different functions depending on the individual and situation. For example, a re-​analysis of the measure used to develop the four-​function model of NSSI (Nock & Prinstein, 2004) found that 21.5% of the sample endorsed at least one item within three social functions (i.e., social influence, automatic functions, and nonconformist peer identification; Dahlstrom, Zettergvist, Lundh, & Svedin, 2015). The social functions of NSSI, however, remain understudied and possibly underidentified (Bentley, Nock, & Barlow, 2014). The available evidence suggests that NSSI is influenced by social or interpersonal factors, despite limited endorsement on self-​report function measures (Power, Smith, & Beaudette, 2016). For example, NSSI is widely recognized as being socially contagious. As early as 1968, an “epidemic” of self-​injury was described on an adolescent unit in which NSSI spread socially among 11 patients (Matthews, 1968). Consistent with social contagion theory (Christakis & Fowler, 2013), NSSI likely spreads through social modeling and influence, although the precise pathway remains unclear (Giletta, Burk, Scholte, Engels, & Prinstein, 2013; Hasking, Andrews, & Martin, 2013). Regardless, social contagion is often a focus of clinicians working in schools or

10  Noel C. Slesinger et al.

inpatient units (Hasking et al., 2016; Zhu et al., 2016), and suggests the need to consider the impact of the social environment on the development and maintenance of NSSI.

NSSI as a Distinct Condition Although NSSI is now commonly accepted as a condition separate from SSI, it remains commonly associated with borderline personality disorder (BPD) (Andover, Schatten, & Morris, 2018). This association is not without justification: NSSI is a diagnostic criterion for BPD (American Psychiatric Association, 2013)  and rates of NSSI in BPD have been shown to be as high as 80% (Andrewes, Hulbert, Cotton, Betts, & Chanen, 2017b; Sleuwaegen, Houben, Claes, Berens, & Sabbe, 2017). Further, when compared to those without NSSI, individuals with NSSI endorse a greater number of BPD symptoms (Kaess et al., 2016). There is also consensus that while NSSI is common in BPD –​and BPD is common in NSSI  –​not everyone who engages in NSSI has BPD. Rates of BPD in NSSI vary, and typically range around half of samples examined (Glenn & Klonsky, 2013; Selby, Bender, Gordon, Nock, & Joiner, 2012). The co-​occurrence of BPD also signals a more severe clinical presentation of NSSI. Several studies have found co-​occurring BPD and NSSI to be associated with greater NSSI frequency, severity, and versatility, worse difficulties in emotion regulation, higher rates of co-​occurrence with other mental disorders, and worse treatment outcomes (Bracken-​Minor & McDevitt-​Murphy, 2014; Turner et al., 2015; Ward et al., 2013). A reliance on binary diagnostic categories, however, may obscure a more nuanced association between BPD and NSSI (Kaess et al., 2016). Although most studies examining BPD in NSSI have used a categorical diagnosis of BPD, some limited evidence suggests that there is substantial variation in BPD symptoms among those with NSSI (Hayes, Lengel, Styer, & Washburn, 2016). For example, while 58% of our acute-​care sample of patients with NSSI (n  =  1,267) may be at risk for BPD, symptoms vary dramatically on a continuum. As shown in Figure 1.1, borderline symptoms, as measured by the Borderline Evaluation of Severity over Time scale, reflect a normal curve, with the majority reporting moderate symptoms of BPD. Consistent with the overwhelming evidence of dimensionality in personality traits and the growing movement away from categorical to dimensional diagnosis of personality disorders (Bagby & Widiger, 2018; Kotov et al., 2017), BPD within NSSI is likely best understood through dimensional assessment of normative personality gone awry. In addition to BPD, NSSI is associated with increased risk for both internalizing and externalizing psychopathology (Glenn & Klonsky, 2013; In-​Albon, Burll, Ruf, & Schmid, 2013; Meszaros, Horvath, & Balazs, 2017; Zielinski, Hill, & Veilleux, 2018). Mood disorders, particularly major depressive disorder, are typically found among the majority of individuals with NSSI, especially for those with clinically relevant levels of NSSI (Kiekens et al., 2018; Turner et al., 2015).

60 40 0

20

Frequency

80

100

Nonsuicidal Self-Injury: The Basics  11

0

20

40 BEST: Total Score

60

80

Figure 1.1 Variability of borderline personality symptoms among acute-​care patients with NSSI (n = 1,267). Note: BEST = Borderline Evaluation of Severity over Time.

The co-​occurrence of NSSI, however, is not limited to mood disorders. In a meta-​analysis examining 56 studies, elevated risk for NSSI was found among nearly all emotional disorders, including major depressive disorder, dysthymia, generalized anxiety disorder, panic disorder, obsessive compulsive disorder, and post​traumatic stress disorder (Bentley, Cassiello-​Robbins, Vittorio, Sauer-​ Zavala, & Barlow, 2015). In addition to emotional disorders, NSSI has been associated  with disruptive behavioral, neurodevelopmental, substance use, and eating disorders (Meszaros et al., 2017; Nock, Joiner, Gordon, Lloyd-​Richardson, & Prinstein, 2006; Turner et al., 2015). Understanding the comorbidity of mental disorders and NSSI is important not only for characterizing the severity and impairment of NSSI, but also for untangling the mechanisms of NSSI. For example, comorbid mental disorders have been shown to mediate the association between NSSI and distress tolerance, child maltreatment, and attention-​deficit/​hyperactivity disorder (Auerbach et al., 2014; Balazs, Gyori, Horvath, Meszaros, & Szentivanyi, 2018; Lin,You,Wu, & Jiang, 2017). It is likely, however, that transdiagnostic factors shared across many of these disorders may provide more explanation of the mechanisms of NSSI than categorical diagnoses. For example, negative urgency (Riley, Combs, Jordan, & Smith, 2015), disinhibition (Claes et al., 2012; Ross, Heath, & Toste,

12  Noel C. Slesinger et al.

2009), emotional reactivity (Claes, Smits, & Bijttebier, 2014; Nock, Wedig, Holmberg, & Hooley, 2008; Smith, Hayes, Styer, & Washburn, 2017), and self-​ criticism (You, Lin, & Leung, 2015; Zelkowitz & Cole, 2018) have all been associated with NSSI, and may prove more useful than broad categorical diagnoses in understanding the development and maintenance of NSSI.

Beyond the Basics Our understanding of NSSI is strong, but much remains to be known. To move beyond the basics, we recommend that the following areas be explored in more depth over the next decade: 1. Articulation of the mechanisms subsumed under the umbrella emotion regulation function of NSSI 2. Greater understanding of the neurobiology of NSSI 3. Differentiation of NSSI from other mental disorders, including the validity and utility of NSSI as a specific mental disorder 4. Better understanding of the mechanisms behind the association between NSSI and suicide, including their likely transactional associations 5. Identification and understanding of variations of NSSI presentation, including chronic and severe NSSI 6. Assessment, treatment, and prevention of NSSI 7. The influence of social media on NSSI 8. The etiology of NSSI, including an understanding of transdiagnostic risk factors, as well as risk factors that are specific to NSSI

Conclusion Our understanding of NSSI has developed significantly in the past 15  years. While the evolution of NSSI has been substantial, there is still much work to be done. NSSI is a perplexing condition that continues to be misunderstood by the public and clinicians alike; however, progress is being made.With greater dissemination of evidence-​based information about NSSI, we expect improvements in the identification, treatment, and prevention of NSSI will follow.

References American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders, 5th edition: DSM-​5. Washington, DC: American Psychiatric Publishing. Ammerman, B.  A., Jacobucci, R., Kleiman, E.  M., Uyeji, L.  L., & McCloskey, M.  S. (2018). The relationship between nonsuicidal self-​injury age of onset and severity of self-​harm. Suicide and Life Threatening Behavior, 48(1), 31–​37. doi:10.1111/​sltb.12330 Ammerman, B. A., Jacobucci, R., & McCloskey, M. S. (2018). Using exploratory data mining to identify important correlates of nonsuicidal self-​injury frequency. Psychology of Violence, 8(4), 515–​525. doi:10.1037/​vio0000146

Nonsuicidal Self-Injury: The Basics  13 Andover, M. S., Schatten, H. T., & Morris, B. W. (2018). Suicidal and nonsuicidal self-​ injury in borderline personality disorder. In B. Stanley & A. S. New (Eds.), Borderline personality disorder (pp. 129–​148). Oxford: Oxford University Press. Andrewes, H.  E., Hulbert, C., Cotton, S.  M., Betts, J., & Chanen, A.  M. (2017a). Ecological momentary assessment of nonsuicidal self-​injury in youth with borderline personality disorder. Personality Disorders, 8(4), 357–​365. doi:10.1037/​per0000205 Andrewes, H.  E., Hulbert, C., Cotton, S.  M., Betts, J., & Chanen, A.  M. (2017b). Relationships between the frequency and severity of non-​suicidal self-​injury and suicide attempts in youth with borderline personality disorder. Early Intervention in Psychiatry. doi:10.1111/​eip.12461 Angelotta, C. (2015). Defining and refining self-​ harm:  A historical perspective on nonsuicidal self-​injury. Journal of Nervous and Mental Disease, 203(2), 75–​80. Auerbach, R.  P., Kim, J.  C., Chango, J.  M., Spiro, W.  J., Cha, C., Gold, J., … Nock, M. K. (2014). Adolescent nonsuicidal self-​injury: Examining the role of child abuse, comorbidity, and disinhibition. Psychiatry Research, 220(1–​2), 579–​584. doi:10.1016/​ j.psychres.2014.07.027 Bagby, R. M., & Widiger, T. A. (2018). Five Factor Model personality disorder scales: An introduction to a special section on assessment of maladaptive variants of the five factor model. Psychological Assessment, 30(1), 1–​9. doi:10.1037/​pas0000523 Balazs, J., Gyori, D., Horvath, L. O., Meszaros, G., & Szentivanyi, D. (2018). Attention-​ deficit hyperactivity disorder and nonsuicidal self-​ injury in a clinical sample of adolescents:T role of comorbidities and gender. BMC Psychiatry, 18(1), 34. doi:10.1186/​ s12888-​018-​1620-​3 Bentley, K.  H., Cassiello-​ Robbins, C.  F., Vittorio, L., Sauer-​ Zavala, S., & Barlow, D.  H. (2015). The association between nonsuicidal self-​injury and the emotional disorders: A meta-​analytic review. Clinical Psychology Review, 37, 72–​88. doi:10.1016/​ j.cpr.2015.02.006 Bentley, K.  H., Nock, M.  K., & Barlow, D.  H. (2014). The Four-​Function model of nonsuicidal self-​injury. Clinical Psychological Science, 2(5), 638–​ 656. doi:10.1177/​ 2167702613514563 Bracken-​Minor, K.  L., & McDevitt-​Murphy, M.  E. (2014). Differences in features of non-​suicidal self-​injury according to borderline personality disorder screening status. Archives of Suicide Research, 18(1), 88–​103. doi:10.1080/​13811118.2013.809040 Bresin, K., & Schoenleber, M. (2015). Gender differences in the prevalence of nonsuicidal self-​injury:  A meta-​analysis. Clinical Psychology Review, 38, 55–​ 64. doi:10.1016/​ j.cpr.2015.02.009 Carpenter, R. W., & Trull, T. J. (2015). The pain paradox: Borderline personality disorder features, self-​harm history, and the experience of pain. Personality Disorders, 6(2), 141–​ 151. doi:10.1037/​per0000112 Cerutti, R., Presaghi, F., Manca, M., & Gratz, K. L. (2012). Deliberate self-​harm behavior among Italian young adults:  Correlations with clinical and nonclinical dimensions of personality. American Journal of Orthopsychiatry, 82(3), 298–​ 308. doi:10.1111/​ j.1939-​0025.2012.01169.x Christakis, N. A., & Fowler, J. H. (2013). Social contagion theory: Examining dynamic social networks and human behavior. Statistics in Medicine, 32(4), 556–​577. doi:10.1002/​ sim.5408 Claes, L., Jimenez-​Murcia, S., Aguera, Z., Castro, R., Sanchez, I., Menchon, J. M., & Fernandez-​ Aranda, F. (2012). Male eating disorder patients with and without

14  Noel C. Slesinger et al. non-​suicidal self-​injury: A comparison of psychopathological and personality features. European Eating Disorders Review, 20(4), 335–​338. doi:10.1002/​erv.1161 Claes, L., Smits, D., & Bijttebier, P. (2014). The Dutch version of the Emotion Reactivity Scale:  Validation and relation with various behaviors in a sample of high school students. European Journal of Psychological Assessment, 30(1), 73–​79. Claes, L., Vandereycken, W., & Vertommen, H. (2007). Self-​injury in female versus male psychiatric patients: A comparison of characteristics, psychopathology and aggression regulation. Personality and Individual Differences, 42(4), 611–​ 621. doi:10.1016/​ j.paid.2006.07.021 Crowell, S. E., & Kaufman, E. A. (2016). Development of self-​inflicted injury: Comor­ bidities and continuities with borderline and antisocial personality traits. Developmental Psychopathology, 28(4pt1), 1071–​1088. doi:10.1017/​S0954579416000705 Dahlstrom, O., Zettergvist, M., Lundh, L.-​G., & Svedin, C.  G. (2015). Functions of nonsuicidal self-​injury: Exploratory and confirmatory factor analyses in a large community sample of adolescents. Psychological Assessment, 27(1), 302–​313. Favazza, A.  R. (1998). The coming of age of self-​mutilation. Journal of Nervous and Mental Disease, 186(6), 259–​269. Fox, K.  R., Millner, A.  J., & Franklin, J.  C. (2016). Classifying nonsuicidal overdoses:  Nonsuicidal self-​injury, suicide attempts, or neither? Psychiatry Research, 244, 235–​242. doi:10.1016/​j.psychres.2016.07.052 Giletta, M., Burk, W. J., Scholte, R. H., Engels, R. C., & Prinstein, M. J. (2013). Direct and indirect peer socialization of adolescent nonsuicidal self-​injury. Journal of Research on Adolescence, 23(3), 450–​463. doi:10.1111/​jora.12036 Glenn, C. R., & Klonsky, E. D. (2013). Nonsuicidal self-​injury disorder: An empirical investigation in adolescent psychiatric patients. Journal of Clinical Child and Adolescent Psychology, 42(4), 496–​507. doi:10.1080/​15374416.2013.794699 Gregory, R. J., & Mustata, G. T. (2012). Magical thinking in narratives of adolescent cutters. Journal of Adolescence, 35(4), 1045–​1051. doi:10.1016/​j.adolescence.2012.02.012 Hamza, C. A., & Willoughby,T. (2015). Nonsuicidal self-​injury and affect regulation: Recent findings from experimental and ecological momentary assessment studies and future directions. Journal of Clinical Psychology, 71(6), 561–​574. doi:10.1002/​jclp.22174 Hasking, P., Andrews, T., & Martin, G. (2013). The role of exposure to self-​injury among peers in predicting later self-​injury. Journal of Youth and Adolescence, 42(10), 1543–​1556. doi:10.1007/​s10964-​013-​9931-​7 Hasking, P., Heath, N. L., Kaess, M., Lewis, S. P., Plener, P. L., Walsh, B. W., … Wilson, M. S. (2016). Position paper for guiding response to non-​suicidal self-​injury in schools. School Psychology International, 37(6), 644–​663. doi:10.1177/​0143034316678656 Hayes, N.  A., Lengel, G.  J., Styer, D., & Washburn, J.  J. (2016). Correlates of Borderline Personality Disorder in an Acute Care Sample of Nonsuicidal Self-​Injury in Patients. Paper presented at the Annual Conference of the Society for Personality Assessment, Chicago, IL. Houben, M., Claes, L.,Vansteelandt, K., Berens, A., Sleuwaegen, E., & Kuppens, P. (2017). The emotion regulation function of nonsuicidal self-​injury: A momentary assessment study in inpatients with borderline personality disorder features. Journal of Abnormal Psychology, 126(1), 89–​95. doi:10.1037/​abn0000229 In-​Albon, T., Burll, M., Ruf, C., & Schmid, M. (2013). Non-​suicidal self-​injury and emotion regulation: A review on facial emotion recognition and facial mimicry. Child and Adolescent Psychiatry and Mental Health, 7(5).

Nonsuicidal Self-Injury: The Basics  15 International Society for the Study of Self-​injury (ISSS). (2018, May).What is self-​injury? Retrieved from: https://​itriples.org/​about-​self-​injury/​what-​is-​self-​injury. Jacobson, C. M., & Gould, M. (2007). The epidemiology and phenomenology of non-​ suicidal self-​injurious behavior among adolescents: A critical review of the literature. Archives of Suicide Research, 11(2), 129–​147. doi:10.1080/​13811110701247602 Kaess, M., Brunner, R., Parzer, P., Edanackaparampil, M., Schmidt, J., Kirisgil, M., … Resch, F. (2016). Association of adolescent dimensional borderline personality pathology with past and current nonsuicidal self-​injury and lifetime suicidal behavior: A clinical multicenter study. Psychopathology, 49(5). Kaess, M., Parzer, P., Mattern, M., Plener, P.  L., Bifulco, A., Resch, F., & Brunner, R. (2013). Adverse childhood experiences and their impact on frequency, severity, and the individual function of nonsuicidal self-​injury in youth. Psychiatry Research, 206(2–​3), 265–​272. doi:10.1016/​j.psychres.2012.10.012 Kerr, P.  L., Muehlenkamp, J.  J., & Turner, J.  M. (2010). Nonsuicidal self-​injury:  A review of current research for family medicine and primary care physicians. Journal of the American Board of Family Medicine, 23(2), 240–​ 259. doi:10.3122/​ jabfm.2010.02.090110 Kessel, N. (1965). Repeated acts of self-​poisoning and self-​injury. Journal of the Royal Society of Medicine, 59, 89–​92. Kiekens, G., Hasking, P., Bruffaerts, R., Claes, L., Baetens, I., Boyes, M., … Whitlock, J. (2017). What predicts ongoing nonsuicidal self-​injury? A  comparison between persistent and ceased self-​injury in emerging adults. Journal of Nervous and Mental Disease, 205(10), 762–​770. doi:10.1097/​NMD.0000000000000726 Kiekens, G., Hasking, P., Claes, L., Mortier, P., Auerbach, R. P., Boyes, M., … Bruffaerts, R. (2018). The DSM-​ 5 nonsuicidal self-​ injury disorder among incoming college students:  Prevalence and associations with 12-​month mental disorders and suicidal thoughts and behaviors. Depression and Anxiety. doi:10.1002/​da.22754 Kirkcaldy, B., Richardson-​Vejlgaard, R., & Siefen, G. (2009). Birth order: Self-​injurious and suicidal behavior among adolescents. Psychology, Health and Medicine, 14(1), 9–​16. doi:10.1080/​13548500801983058 Klonsky, E. D. (2007). The functions of deliberate self-​injury: A review of the evidence. Clinical Psychology Review, 27, 226–​239. Klonsky, E.  D. (2011). Non-​ suicidal self-​ injury in United States adults:  Prevalence, sociodemographics, topography and functions. Psychological Medicine, 41(9), 1981–​ 1986. doi:10.1017/​S0033291710002497 Klonsky, E. D., Glenn, C. R., Styer, D. M., Olino, T. M., & Washburn, J. J. (2015). The functions of nonsuicidal self-​injury: Converging evidence for a two-​factor structure. Child and Adolescent Psychiatry and Mental Health, 9, 44. doi:10.1186/​s13034-​015-​0073-​4 Kotov, R., Krueger, R. F., Watson, D., Achenbach, T. M., Althoff, R. R., Bagby, R. M., … Zimmerman, M. (2017).The Hierarchical Taxonomy of Psychopathology (HiTOP): A dimensional alternative to traditional nosologies. Journal of Abnormal Psychology, 126(4), 454–​477. doi:10.1037/​abn0000258 Kranzler, A., Fehling, K. B., Lindqvist, J., Brillante, J., Yuan, F., Gao, X., … Selby, E. A. (2018). An ecological investigation of the emotional context surrounding nonsuicidal self-​injurious thoughts and behaviors in adolescents and young adults. Suicide and Life Threatening Behavior, 48(2), 149–​159. doi:10.1111/​sltb.12373 Kreitman, N., Philip, A.  E., Greer, S., & Bagley, C.  R. (1969). Parasuicide. The British Journal of Psychiatry, 115(523), 746–​747.

16  Noel C. Slesinger et al. Lin, M.  P., You, J., Wu, Y.  W., & Jiang, Y. (2017). Depression mediates the relationship between distress tolerance and nonsuicidal self-​injury among adolescents: One-​year follow-​up. Suicide and Life Threatening Behavior. doi:10.1111/​sltb.12382 Lloyd-​Richardson, E. E., Perrine, N., Dierker, L., & Kelley, M. L. (2007). Characteristics and functions of non-​ suicidal self-​ injury in a community sample of adolescents. Psychological Medicine, 37(8), 1183–​1192. doi:10.1017/​S003329170700027X Mars, B., Heron, J., Crane, C., Hawton, K., Lewis, G., Macleod, J., … Gunnell, D. (2014). Clinical and social outcomes of adolescent self-​harm: Population-​based birth cohort study. BMJ, 349, g5954. doi:10.1136/​bmj.g5954 Matthews, P. C. (1968). Epidemic self-​injury in an adolescent unit. International Journal of Social Psychiatry, 14(2), 125–​133. McKenzie, K. C., & Gross, J. J. (2014). Nonsuicidal self-​injury: An emotion regulation perspective. Psychopathology, 47(4), 207–​219. doi:10.1159/​000358097 Menninger, K. (1938). Man against himself. New York: Harcourt Brace & World. Meszaros, G., Horvath, L.  O., & Balazs, J. (2017). Self-​injury and externalizing pathology:  A systematic literature review. BMC Psychiatry, 17(1), 160. doi:10.1186/​ s12888-​017-​1326-​y Morgan, H.  G., Burns-​Cox, C.  J., Pocock, H., & Pottle, S. (1975). Deliberate self-​ harm:  Clinical and socio-​economic characteristics of 368 patients. British Journal of Psychiatry, 127(6), 564–​574. Muehlenkamp, J. J., Claes, L., Havertape, L., & Plener, P. L. (2012). International prevalence of adolescent non-​suicidal self-​injury and deliberate self-​harm. Child Adolescent Psychiatry and Mental Health, 6, 10. doi:10.1186/​1753-​2000-​6-​10 Nock, M.  K., Joiner, T.  E., Jr., Gordon, K.  H., Lloyd-​ Richardson, E., & Prinstein, M.  J. (2006). Non-​ suicidal self-​ injury among adolescents:  Diagnostic correlates and relation to suicide attempts. Psychiatry Research, 144(1), 65–​ 72. doi:10.1016/​ j.psychres.2006.05.010 Nock, M. K., & Prinstein, M. J. (2004). A functional approach to the assessment of self-​ mutilative behavior. Journal of Consulting and Clinical Psychology, 72(5), 885–​890. Nock, M.  K., Wedig, M.  M., Holmberg, E.  B., & Hooley, J.  M. (2008). The emotion reactivity scale: Development, evaluation, and relation to self-​injurious thoughts and behaviors. Behavior Therapy, 39(2), 107–​116. doi:10.1016/​j.beth.2007.05.005 Plener, P. L., Allroggen, M., Kapusta, N. D., Brahler, E., Fegert, J. M., & Groschwitz, R. C. (2016).The prevalence of Nonsuicidal Self-​Injury (NSSI) in a representative sample of the German population. BMC Psychiatry, 16(1), 353. doi:10.1186/​s12888-​016-​1060-​x Power, J., Smith, H. P., & Beaudette, J. N. (2016). Examining Nock and Prinstein’s four-​ function model with offenders who self-​injure. Personality Disorders, 7(3), 309–​314. doi:10.1037/​per0000177 Purlington, A., & Whitlock, J. (2010). Non-​ suicidal self-​ injury in the media. The Prevention Researcher, 17(1), 11–​14. Riley, E. N., Combs, J. L., Jordan, C. E., & Smith, G. T. (2015). negative urgency and lack of perseverance: Identification of differential pathways of onset and maintenance risk in the longitudinal prediction of nonsuicidal self-​injury. Behavior Therapy, 46, 439–​448. Robertson, C.  D., Miskey, H., Mitchell, J., & Nelson-​Gray, R. (2013). Variety of self-​ injury: Is the number of different methods of non-​suicidal self-​injury related to personality, psychopathology, or functions of self-​injury? Archives of Suicide Research, 17(1), 33–​40. doi:10.1080/​13811118.2013.748410

Nonsuicidal Self-Injury: The Basics  17 Ross, S., Heath, N., & Toste, J. R. (2009). Non-​suicidal self-​injury and eating pathology in high school students. American Journal of Orthopsychiatry, 79(1), 83–​92. Selby, E. A., Bender, T. W., Gordon, K. H., Nock, M. K., & Joiner, T. E., Jr. (2012). Non-​ suicidal self-​injury (NSSI) disorder:  A preliminary study. Personality Disorders, 3(2), 167–​175. doi:10.1037/​a0024405 Sleuwaegen, E., Houben, M., Claes, L., Berens, A., & Sabbe, B. (2017). The relationship between non-​suicidal self-​injury and alexithymia in borderline personality disorder: “Actions instead of words”. Comprehensive Psychiatry, 77, 80–​88. doi:10.1016/​ j.comppsych.2017.06.006 Smith, K. E., Hayes, N. A., Styer, D. M., & Washburn, J. J. (2017). Emotional reactivity in a clinical sample of patients with eating disorders and nonsuicidal self-​injury. Psychiatry Research, 257, 519–​525. doi:10.1016/​j.psychres.2017.08.014 Sornberger, M. J., Heath, N., Toste, J. R., & McLouth, R. (2012). Nonsuicidal self-​injury and gender: Patterns of prevalence, methods, and locations among adolescents. Suicide and Life Threatening Behavior, 42(3), 266–​278. doi:10.1111/​j.1943-​278X.2012.00088.x St. Germain, S. A., & Hooley, J. M. (2012). Direct and indirect forms of non-​suicidal self-​ injury: Evidence for a distinction. Psychiatry Research, 197(1–​2), 78–​84. doi:10.1016/​ j.psychres.2011.12.050 Turner, B. J., Dixon-​Gordon, K. L., Austin, S. B., Rodriguez, M. A., Zachary Rosenthal, M., & Chapman, A. L. (2015). Non-​suicidal self-​injury with and without borderline personality disorder: Differences in self-​injury and diagnostic comorbidity. Psychiatry Research, 230(1), 28–​35. doi:10.1016/​j.psychres.2015.07.058 Turner, B. J., Layden, B. K., Butler, S. M., & Chapman, A. L. (2013). How often, or how many ways: Clarifying the relationship between non-​suicidal self-​injury and suicidality. Archives of Suicide Research, 17(4), 397–​415. Vansteelandt, K., Houben, M., Claes, L., Berens, A., Sleuwaegen, E., Sienaert, P., & Kuppens, P. (2017). The affect stabilization function of nonsuicidal self injury in Borderline Personality Disorder: An ecological momentary assessment study. Behavior Research and Therapy, 92, 41–​50. doi:10.1016/​j.brat.2017.02.003 Ward, A., Bender, T.  W., Gordon, K.  H., Nock, M.  K., Joiner, T.  E., & Selby, E.  A. (2013). Post-​therapy functional impairment as a treatment outcome measure in non-​ suicidal self-​injury disorder using archival data. Personality and Mental Health, 7(1), 69–​79. doi:10.1002/​pmh.1213 Washburn, J.  J. (2014). Self-​ Injury:  Simple answers to complex problems. Chattanooga, TN: Alexian Brothers Press. Washburn, J.  J., Potthoff, L.  M., Juzwin, K.  R., & Styer, D. (2015). Assessing DSM-​ 5 nonsuicidal self-​ injury disorder in a clinical sample. Psychological Assessment, 27(1),  31–​41. Washburn, J.  J., Styer, D., Gebhardt, M., & Aldridge, D. (2013). Eating disorders and non-​suicidal self-​injury: From primary care to inpatient hospitalization. In Non-​suicidal self-​injury in eating disorders: Advancements in etiology and treatment (pp. 319–​340). Berlin: Springer-​Verlag. Wester, K.,Trepal, H., & King, K. (2017). Nonsuicidal self-​injury: Increased prevalence in engagement. Suicide and Life Threatening Behavior,  1–​9. You, J., Lin, M. P., & Leung, F. (2015). A longitudinal moderated mediation model of nonsuicidal self-​injury among adolescents. Journal of Abnormal Child Psychology, 43(2), 381–​390. doi:10.1007/​s10802-​014-​9901-​x

18  Noel C. Slesinger et al. You, J., Ren, Y., Zhang, X., Wu, Z., Xu, S., & Lin, M.-​P. (2018). Emotion dysregulation and nonsuicidal self-​injury: A meta-​analytic review. Neuropsychiatry, 8(2), 733–​748. Zelkowitz, R.  L., & Cole, D.  A. (2018). Self-​criticism as a transdiagnostic process in nonsuicidal self-​injury and disordered eating:  Systematic review and meta-​analysis. Suicide and Life Threatening Behavior. doi:10.1111/​sltb.12436 Zhu, L.,Westers, N. J., Horton, S. E., King, J. D., Diederich, A., Stewart, S. M., & Kennard, B.  D. (2016). Frequency of exposure to and engagement in nonsuicidal self-​injury among inpatient adolescents. Archives of Suicide Research, 20(4), 580–​590. doi:10.1080/​ 13811118.2016.1162240 Zielinski, M. J., Hill, M. A., & Veilleux, J. C. (2018). Is the first cut really the deepest? Frequency and recency of nonsuicidal self-​injury in relation to psychopathology and dysregulation. Psychiatry Research, 259, 392–​397. doi:10.1016/​j.psychres.2017.10.030

Chapter 2

Nonsuicidal Self-​I njury Beyond the Basics Sarah E. Victor and Angelina Yiu

Introduction Research on NSSI has expanded rapidly over the past few decades. In spite of this important work, there remain substantial gaps in our understanding of NSSI and related phenomena. In this chapter, we focus on future directions for NSSI research that are not explicitly addressed in other chapters. We spotlight some recent, exciting work in two critical areas: specificity of NSSI and heterogeneity within NSSI. We also highlight a variety of potential future directions in these and other areas of NSSI research.

What Makes NSSI Unique? NSSI is, perhaps unsurprisingly, associated with a host of problematic thoughts, feelings, behaviors, and experiences. Meta-​ analyses indicate that NSSI is associated with dissociation (Calati, Bensassi, & Courtet, 2017), eating disorders (Cucchi et  al., 2016), psychosis (Honings, Drukker, Groen, & van Os, 2016), peer victimization (van Geel, Goemans, & Vedder, 2015), impulsivity (Hamza, Willoughby, & Heffer, 2015), hopelessness (Fox et  al., 2015), and emotional disorders (Bentley, Cassiello-​Robbins, Vittorio, Sauer-​Zavala, & Barlow, 2015). Because NSSI is associated with a range of pathology, it is unsurprising that studies comparing people with NSSI to so-​called “healthy controls” typically find a host of factors that differentiate these groups. This is also true in clinical populations; co-​occurring NSSI is associated with greater impairment among patients with eating disorders (Islam et al., 2015), post​traumatic stress disorder (Calhoun et al., 2017), mood disorders (Goldstein et al., 2005), and substance use disorders (Anestis, Tull, Lavender, & Gratz, 2014), although this may be attributable to the general association between the presence of multiple disorders and impairment (Newman et al., 1996). The existing literature on the association between NSSI and other concerns highlights the clinical importance of assessing and treating NSSI in a variety of conditions; however, it does little to clarify the conceptualization of NSSI as a

20  Sarah E. Victor and Angelina Yiu

unique condition when compared to other mental disorders. In this chapter, we explore several possibilities for explaining what, if anything, makes NSSI unique among other mental disorders and conditions.

Is It About Emotion (Dys)Regulation? NSSI is commonly viewed as a condition predominantly related to emotion dysregulation (Zelkowitz, Cole, Han, & Tomarken, 2016). Yet, evidence supports the role of emotion dysregulation as a transdiagnostic risk factor for psychopathology more broadly (Lukas, Ebert, Fuentes, Caspar, & Berking, 2017), and examinations of the unique association between NSSI and emotion dysregulation have been far from conclusive. For example, research comparing adults with clinically significant NSSI to adults with eating disorder behaviors (EDB) suggest that these groups do not differ on self-​reported emotion dysregulation (Buckholdt et al., 2014). Further, when undergraduates meeting criteria for borderline personality disorder (BPD) with and without co-​occurring NSSI disorder (American Psychiatric Association, 2013) were compared to students with NSSI disorder without co-​occurring BPD, those with NSSI disorder report significantly lower levels of emotion dysregulation than those with BPD, regardless of the co-​occurrence of NSSI disorder (Bracken-​Minor & McDevitt-​Murphy, 2014). These findings suggest that third variables, such as BPD symptoms, may contribute to the association between NSSI and emotion dysregulation. In addition to NSSI research utilizing broad measures of emotion dysregulation, there is some evidence that NSSI may be more closely associated with specific facets of emotion dysregulation, such as emotional intensity, reactivity, and processing. In response to several trials of a rumination induction task, Arbuthnott and colleagues (Arbuthnott, Lewis, & Bailey, 2015) found that undergraduate students with a history of NSSI showed a sharp, curvilinear increase in negative emotions after the first trial, while students with EDB showed a slower, linear increase in negative emotions across multiple trials. Daily diary research investigating NSSI and EDB in daily life found that NSSI behaviors were preceded by more negative emotions than either fasting or binge/​purge behaviors, and that negative mood variability over the course of the day was associated with increased odds of NSSI, but not with increased odds of EDB (Turner,Yiu, Claes, Muehlenkamp, & Chapman, 2016). Further, a study comparing patients with eating disorders (ED), NSSI, and co-​occurring ED and NSSI found greater emotional reactivity when NSSI was present, regardless of ED (Smith, Hayes, Styer & Washburn, 2017). Collectively, these results support affect regulation models of NSSI, in which NSSI is conceptualized as an attempt to regulate negative affect (Klonsky et  al., 2015), but suggest that increased negative mood reactivity, variability, and intensity may be more uniquely associated with NSSI than emotion dysregulation broadly.

Beyond the Basics  21

Is It About Clinical Severity and Comorbidity? The high rate of co-​occurrence of NSSI with other mental disorders (Tschan, Peter-​Ruf, Schmid, & In-​Albon, 2017) suggests that greater clinical severity may, in and of itself, be a unique correlate of NSSI. For example, research from large, multi-​ site surveys of secondary school students in Australia indicates that among youth with only one condition, those engaging in NSSI are more distressed than youth engaging in alcohol use (Andrews, Martin, & Hasking, 2012). Further, in comparison to youth who engage in fire-​setting, youth engaging in NSSI show more evidence of mental health problems, such as co-​occurring mental disorders, past mental health treatment, a family or peer history of self-​harm behavior, thoughts of suicide, and past suicide attempts (Tanner, Hasking, & Martin, 2016). Among adults, those with recent NSSI exhibit greater suicide-​proneness and higher rates of suicidality than those with indirect self-​harm behaviors, such as disordered eating, substance use, or interpersonally risky behavior (St. Germain & Hooley, 2012). A series of studies involving adolescents receiving inpatient psychiatric care with either recent NSSI or a recent suicide attempt further support the overall clinical severity associated with NSSI. Adolescents with NSSI consistently demonstrated more clinically severe presentations when compared to adolescents with a recent suicide attempt, including higher rates of major depressive disorder (Kim et  al., 2015a), use of a greater number of psychotropic medications (Seymour et al., 2016), and earlier lifetime onset of self-​harm behavior (Kim et al., 2015b). Further, the adolescents with NSSI reported earlier onset of suicidal thoughts and exhibited higher identification with suicide/​ death content in an implicit association task, even after controlling for current levels of suicidal ideation (Dickstein et al., 2015). Collectively, evidence suggests that NSSI is associated with greater clinical severity even when compared to other psychiatric conditions (e.g., disordered eating, alcohol use, recent suicide attempts). The greater clinical severity observed in NSSI is consistent with Joiner’s Interpersonal–​Psychological Theory of Suicidal Behavior (Joiner, 2005) and other ideation-​to-​action theories of suicide (Klonsky, Saffer, & Bryan, 2017), which argue that individuals do not die by suicide unless there is both the desire to die and the capability or capacity to engage in lethal suicidal behavior. The association between NSSI and suicidal behavior may, therefore, be due to its association with both psychic distress (related to desire for suicide) and habituation to pain and injury (related to capacity for suicidal behavior). It is also possible that engagement in NSSI may increase suicide risk not only through its role in suicidal desire and suicidal capacity directly, but also through its association with other third variables, such as views of the self. For example, in a comparison of adults with recent NSSI to those with indirect self-​harm behaviors, such as disordered eating and reckless sexual behavior, self-​criticism was markedly higher in the NSSI group, while no differences were found with respect to dissociation, depression, aggression, impulsivity, and self-​esteem (St. Germain & Hooley, 2012). Interestingly, daily diary research has indicated that,

22  Sarah E. Victor and Angelina Yiu

among individuals with a history of NSSI and EDB, self-​hatred is associated with increased likelihood of binge/​purge behaviors, but not with increased odds of NSSI (Turner et al., 2016). These results suggest that self-​criticism may serve as a general or trait-​like risk factor for NSSI engagement broadly, but that increases in self-​directed negative emotions at the within-​person level may be less specifically tied to NSSI. It is possible that affective changes after engagement in NSSI (such as increases in shame and guilt; Kleindienst et al., 2008; Klonsky, 2009) may serve as a negative feedback loop for increasing painful emotions and critical views of the self, which then contribute to increased suicidal desire and increased desire for continued NSSI, thus further increasing acquired capability for suicidal actions.

Is It About Interpersonal Sensitivity? Youth engaging in NSSI are less likely to seek social support than those engaging in alcohol use (Andrews et al., 2012), and are more likely to experience serious interpersonal problems and bullying victimization than adolescents engaging in fire-​setting (Tanner et al., 2016). Daily diary research indicates that NSSI is more likely in the context of conflicts with another person or feeling rejected/​hurt (Turner et al., 2016). This contrasts with those who engage in fasting or binge/​ purge behaviors, where talking about upsetting memories or events, which is less explicitly interpersonal in nature, is more strongly related to fasting than to NSSI (Turner et al., 2016). NSSI may also, in turn, contribute to interpersonal difficulties; for example, longitudinal research involving college roommates found that roommates who both engaged in NSSI prior to starting college became less close to each other over time than roommate pairs in which one or neither had a history of NSSI (Eisenberg, Golberstein, & Whitlock, 2014). In contrast, roommates who both engaged in binge drinking prior to starting college became closer over the course of their first academic year, suggesting that NSSI may have a unique relationship with interpersonal problems. These findings are consistent with research showing that adolescents with NSSI report greater stress during an interpersonal laboratory task than adolescents with recent suicidal behavior (Kim et al., 2015a), and may suggest that interpersonal sensitivity is uniquely associated with NSSI when compared to other types of problematic behaviors.

The Bottom Line The research presented so far suggests that individuals engaging in NSSI are characterized by increased emotional reactivity, interpersonal sensitivity and interpersonal problems, and that these features may be more pronounced with respect to NSSI than to other difficulties. It is also clear that NSSI is associated with a more severe clinical presentation than other indirectly harmful behaviors and, in some cases, greater severity than that associated with attempted suicide. It is plausible that people with greater psychosocial risk and mental health difficulties are more likely to choose NSSI, either because NSSI is more appealing

Beyond the Basics  23

to these individuals, or because NSSI serves a necessary function, such as affect regulation, that other behaviors do not. It is also likely that NSSI itself is associated with subsequent worsening of mood, distress, and interpersonal functioning, such that NSSI may “cause” these associated problems, rather than the inverse (Houben et al., 2017). Finally, external or environmental factors may explain these group differences. For example, adolescents who have been exposed to NSSI in their family or peers may be at greater overall risk for psychopathology and be more likely to choose NSSI once exposed to the idea as feasible or acceptable (Jarvi, Jackson, Swenson, & Crawford, 2013). Longitudinal research will ultimately be necessary to disentangle these complex and potentially causal, relationships.

What Contributes to Heterogeneity in NSSI? As described in the prior section, NSSI is associated with psychiatric comorbidity, impairment, and risk for suicidal thoughts and behaviors. Yet, researchers and clinicians focused on NSSI are also aware that, among individuals who engage in NSSI, there exists marked heterogeneity with respect to phenomenology, functions, correlates, and perhaps most critically, related outcomes. For this reason, understanding the characteristics associated with severe negative outcomes among self-​injurers is important to better understand the mechanisms underlying NSSI, and to identify the particular individuals engaging in NSSI who may be in greatest need of intervention. Although a variety of cognitive, affective, and demographic constructs have been investigated in relation to features of NSSI, converging evidence across multiple samples remains lacking for almost all potential contributors to heterogeneity. Therefore, we recommend considering the results reported here as preliminary indicators of further research, rather than definitive proof of a particular hypothesized relationship.

Adverse Life Events and NSSI Three recent studies considered how adverse childhood experiences (ACEs) relate to NSSI characteristics and correlates later in life. In two cases, adolescents and young adults receiving psychiatric care reported on multiple types of ACEs, along with NSSI characteristics. Results showed that ACEs were not prospectively associated with NSSI frequency (Kaplan, Tarlow, Stewart, Aguirre, Galen, & Auerbach, 2016) or cross-​sectionally associated with NSSI severity (Kaess et al., 2013). In contrast, these experiences were associated with distinct functions of NSSI; intrapersonal functions, such as affect regulation, were associated with childhood sexual abuse, whereas interpersonal functions, such as interpersonal influence, were associated with paternal antipathy and neglect during childhood (Kaess et al., 2013). Vaughn and colleagues extended this work by using ACEs to identify latent classes among adults with a history of NSSI drawn from a large epidemiological study (Vaughn, Salas-​Wright, Underwood, & Gochez-​Kerr, 2015). Four latent classes were identified based on prevalence of different ACE types. Adults with

24  Sarah E. Victor and Angelina Yiu

low prevalence of all ACE types (class 1) were least likely to have a diagnosis of an Axis I DSM-​IV mental disorder, while adults with high prevalence of all ACE types (class 4) were most likely to have a DSM-​IV diagnosis of a personality disorder. Those reporting childhood sexual abuse but low prevalence of other ACE types (class 2) were characterized by intermediate levels of pathology compared to other groups, with the exception of criminal and violent behaviors; this group showed the lowest reported prevalence. Adults reporting high rates of physical abuse, neglect, and family violence, but with a low prevalence of childhood sexual abuse (class 3), were characterized by elevated rates of alcohol and cannabis use disorders, as well as greater prevalence of criminal and violent behavior (Vaughn et al., 2015). Taken together, these studies suggest that early life experiences predispose not only engagement in NSSI broadly, but also use of NSSI for specific functions or in the context of specific types of other problematic behaviors, which could contribute to variability in outcomes related to NSSI across the lifespan. For example, childhood sexual abuse is associated with self-​criticism, self-​directed negative emotions, and poor self-​image (Lassri, Luyten, Fonagy & Shahar, 2018; Whiffen & MacIntosh, 2005), which may explain the association between this particular type of trauma and intrapersonal functions of NSSI, to the extent that NSSI is often used to cope with self-​directed negative affect and to punish oneself (Fox, Toole, Franklin & Hooley, 2017; Klonsky, 2007). When severity of interpersonal trauma –​defined as number of types of trauma across different developmental stages –​was taken into consideration, an association with the interpersonal functions of NSSI, specifically the interpersonal boundaries function, became evident, further highlighting the heterogeneity of NSSI functions associated with early life experiences (Horowitz & Stermac, 2018). Given the historical view that NSSI engagement was predominantly (or exclusively) among women with symptoms of BPD, it seems likely that the experience of NSSI among individuals who also engage in aggressive, violent, or criminal behaviors has been inadequately investigated. Thus, our empirical understanding of NSSI functions and correlates, as well as the theoretical models that have been developed for NSSI, may capture only a specific subset of individuals engaging in these behaviors. Further research is necessary to determine whether and how heterogeneity with respect to clinical presentation and childhood experiences impact the phenomenology and course of NSSI.

NSSI Heterogeneity Across Racial and Ethnic Groups Research on NSSI in relation to racial or ethnic identification has primarily focused on prevalence rates, with mixed results. For example, research in college students suggests that non-​Hispanic white students are more likely to report NSSI than African-​American students (Eisenberg, Hunt, & Speer, 2013; Kuentzel, Arble, Boutros, Chugani, & Barnett, 2012; Wester & Trepal, 2015),

Beyond the Basics  25

but the inverse was found among community adolescents in the southern U.S. (Latzman, Gratz, Young, Heiden, Damon, & Hight, 2010). These studies also suggest that non-​Hispanic white and Hispanic students may not appreciably differ in NSSI prevalence (Eisenberg et al., 2013; Kuentzel et al., 2012; Wester & Trepal, 2015). Some research suggests that Asian students have a lower prevalence of NSSI than non-​Hispanic white students (Turner, Arya, & Chapman, 2015; Wester & Trepal, 2015), although other studies have failed to find this effect (Eisenberg et al., 2013; Kuentzel et al., 2012). Beyond simple prevalence of NSSI across groups, cultural experience may also moderate the impact of various risk factors for NSSI. For example, among diverse university students seeking treatment at an on-​campus counseling center, correlates of NSSI differed between non-​Hispanic white students and ethnic minority students (Polanco-​Roman, Tsypes, Soffer, & Miranda, 2014). For non-​Hispanic white students, substance use and a history of sexual or physical/​emotional abuse, but not social anxiety symptoms, were associated with NSSI. In contrast, among ethnic minority students, social anxiety symptoms, but not substance use or a history of abuse, were related to NSSI (Polanco-​ Roman et al., 2014). Among individuals engaging in NSSI, research on how racial and ethnic identity relate to NSSI characteristics and course is less common, but suggestive of intriguing possibilities for further development of theoretical models underlying NSSI. For example, university students of Asian descent who reported high orientation towards Asian cultural norms reported, on average, less severe NSSI (i.e., lower frequency, fewer methods), compared to those who reported lower orientation towards Asian cultural norms (Turner et al., 2015). Although these findings are specific to Canada and the population sampled, they highlight the important role of cultural values, norms, and preferences in the development and maintenance of NSSI. These beliefs may influence, for example, expectancies about NSSI or about oneself, consistent with the cognitive-​emotional model of NSSI (Hasking, Whitlock, Voon, & Rose, 2016). In particular, evidence of the role of acculturation in NSSI engagement (Cervantes, Goldbach, Varela & Santisteban, 2014) points to the importance of considering intersectionality of multiple types of diversity, such as ethnic/​racial identity, gender identity, and sexual identity, in understanding the heterogeneity of NSSI.

Heterogeneity in Suicide Risk: What Matters and For Whom? NSSI is a significant risk factor for suicidal behavior, even more so than other known risk factors such as suicidal ideation and depression (Guan, Fox, & Prinstein, 2012; Klonsky, Glenn, & May, 2013). Knowing that NSSI is an indicator of risk for suicide, however, is not enough to determine for whom NSSI and suicide are most strongly associated. Indeed, not all individuals who engage in

26  Sarah E. Victor and Angelina Yiu

NSSI will go on to contemplate, attempt, or die from suicide. Researchers have begun to investigate factors that co-​occur with suicidality among self-​injurers, with implications for understanding the mechanisms that underlie the association between NSSI and suicide. Two studies in community samples have addressed these issues using latent class analyses. In one case, Xin and colleagues (2016) investigated how NSSI, indirect self-​harm and suicidality were related in a large sample of Chinese adolescents. They found support for four latent classes, of which two were characterized by high rates of NSSI and suicidality, with differing prevalence of indirect self-​harm, such as substance use, risky sexual behavior, overeating, or dangerous driving. These groups did not differ with respect to emotion regulation strategies, self-​ esteem, and cognitive/​ affective symptoms of anxiety; however, the group with high indirect self-​harm exhibited greater impulsivity, depression, negative life events, and physical symptoms of anxiety when compared to the group with low indirect self-​harm. The high indirect self-​ harm group also endorsed greater levels of NSSI and suicidality than the low indirect self-​harm class (Xin et  al., 2016). A  similar latent class approach was used by Hamza and Willoughby (2013) to evaluate the association of NSSI and suicidality among Canadian university students; two of the three identified classes were characterized by high levels of NSSI, differing with respect to rates of suicidality. The high NSSI/​high suicidality group reported greater levels of daily hassles, emotion regulation problems, depression and anxiety symptoms, and behavioral inhibition, as well as lower levels of self-​esteem, than the high NSSI/​low suicidality group. Interestingly, the high suicidality/​high NSSI group had lower NSSI severity (lower lifetime frequency, fewer lifetime methods) than the low suicidality/​high NSSI group; the high suicidality/​high NSSI group was also more likely to be alone when engaged in NSSI (Hamza & Willoughby, 2013). This finding highlights the importance of assessing for social context and psychosocial impairment, in addition to NSSI history, to identify individuals at risk for suicidal behavior. In each of these studies, individuals with NSSI and suicidality showed, on average, more evidence of distress, impairment, and dysfunction than individuals with NSSI without suicidality. Interestingly, indirect self-​harm behaviors, such as substance use, were themselves associated with both overt NSSI behaviors and suicidality (Xin et al., 2016), suggesting that these experiences also play a role in risk for suicide. It is possible that individuals who engage in both indirect self-​ harm and direct self-​harm (i.e., NSSI) do so in response to greater emotional distress, which is then associated with suicide risk. The use of multiple types of self-​harm may also suggest that no specific self-​harm behavior “works” to reduce distress, leading to attempts to regulate one’s emotions through multiple mechanisms. It is also possible that individuals engaging in both indirect self-​ harm and NSSI exhibit greater impulsivity, which then contributes to engagement in impulsive suicidal behavior. A final alternative is that indirect self-​harm behaviors serve distinct functions from NSSI, and that difficulties associated

Beyond the Basics  27

with indirect self-​harm are independently associated with suicide risk above and beyond that conferred by NSSI. This possibility may be the most parsimonious way to account for the findings of Hamza and Willoughby (2013) showing that severity of NSSI was, in fact, lower among self-​injurers with comorbid suicidality when compared to those without, pointing to the role of other related behaviors and difficulties beyond NSSI itself in suicide risk. Although critically important, there has been far less longitudinal work investigating risk factors for suicidality among individuals engaging in NSSI. One such study followed a large sample of university students, recruited across multiple colleges and followed over three years (Whitlock et al., 2013). Among individuals who reported NSSI prior to development of suicidal thoughts or behaviors, later suicidality was predicted by more than 20 episodes of lifetime NSSI, lower self-​reported meaning of life, confidants in fewer categories (e.g., peers, parents, professionals), and a history of mental health treatment; pessimistic cognitive style, emotional acceptance, perceived peer isolation, psychological distress, and personal or family history of diagnosed mental illness were not associated with suicidality (Whitlock et al., 2013).This work highlights the potentially important role of meaning-​making as a protective factor against suicidality in this population and supports theoretical models that include the role of values and beliefs in preventing suicidal behavior (e.g., Gratz & Gunderson, 2006).

Contributors to Variability in NSSI Trajectories over Time Cross-​sectional research has begun to clarify features associated with differences in NSSI severity, methods, and functions, but this work does not permit investigation of factors that influence prospective, subsequent changes in NSSI course. Several studies in the last decade have followed large numbers of participants over time, to identify how baseline characteristics influence NSSI trajectories across months or years. Three distinct teams of researchers have conducted longitudinal studies with Chinese youth to better understand predictors of change in NSSI over time. In one study following students over a one-​year interval, latent trajectory modeling using NSSI supported distinctions between “experimental” (i.e., low initial NSSI frequency, decreasing over time), “moderate decreasing” (i.e., medium initial NSSI frequency, decreasing over time), and “high fluctuating” (i.e., persistently high NSSI frequency) groups (Wang, You, Lin, Xu, & Leung, 2016). A separate two-​year longitudinal study found evidence for low NSSI, moderate/​episodic NSSI, and chronic NSSI groups (Barrocas, Giletta, Hankin, Prinstein, & Abela, 2015; Giletta et al., 2015). The study with the longest follow-​up interval, over six years, measured rates of NSSI and speed of change in NSSI over time as they related to baseline characteristics (Law & Shek, 2016). Using latent trajectory modeling, baseline characteristics were able to distinguish between individuals in the lowest severity group and higher severity

28  Sarah E. Victor and Angelina Yiu

groups, but not between groups with greater levels of NSSI. For example, Wang and colleagues (2016) found that impulsive behaviors differentiated between the episodic NSSI and other NSSI groups, but not between the moderate decreasing and high fluctuating groups; unstable relationships, perceived parental criticism, depression, anxiety, and self-​criticism did not differentiate between any of these three classes. Similarly, Barrocas and colleagues (2015) found that depression and rumination were able to differentiate the low NSSI group from other classes but did not differ between the chronic and moderate NSSI groups. Separate analyses in the same data set showed that reciprocal friendships, assessed based on self-​and informant-​report data using sociometric procedures, did not differentiate between the chronic NSSI and other NSSI trajectory groups (Giletta et al., 2015). The chronic NSSI group did, however, have significantly more suicide attempts over the course of follow-​up, even controlling for baseline suicide attempt history (Barrocas et al., 2015), and they exhibited greater self-​reported peer victimization than the other NSSI groups (Giletta et al., 2015). Law and Shek (2016) found a similar pattern in which several baseline characteristics were associated with NSSI onset, but only gender and prosocial attributes were associated with linear rate of change in NSSI, and only prosocial attributes and positive youth development qualities were associated with quadratic rate of change in NSSI. In a hierarchical multiple regression predicting NSSI at wave six, only one baseline characteristic, family non-​intactness, was a significant predictor of NSSI. These results suggest that our current understanding of risk factors for NSSI may be able to identify who is at greatest risk of transitioning from no history of NSSI to any NSSI engagement but may not be adequate to predict those at risk for a more chronic or pernicious course of NSSI among people who have engaged in NSSI.

NSSI Characteristics as Predictors of NSSI Course and Outcome NSSI itself varies markedly in form and function across individuals. For example, NSSI can vary with respect to the use of specific methods, number of methods, frequency, age at onset or offset (duration and/​or recency), medical severity, and functions, or purpose, of NSSI. Understandably, researchers have considered whether specific characteristics of NSSI provide useful information regarding prognosis, course, and outcomes relevant to NSSI, such as suicidality (Victor & Klonsky, 2014). Several of these studies have used structural equation modeling latent variable methods to identify classes of individuals engaging in NSSI that cluster together with respect to multiple types of NSSI characteristics. In one such study, Bracken-​Minor and colleagues used latent variable mixture modeling to distinguish individuals on the basis of NSSI characteristics and then compared these groups with respect to known NSSI correlates in a combined sample of university students and adults (Bracken-​Minor, McDevitt-​Murphy,

Beyond the Basics  29

& Parra, 2012). Five groups were identified, which differed in prevalence on specific NSSI methods, social NSSI functions, and automatic NSSI functions. The two highest severity groups were characterized by moderate to high levels of all NSSI methods and high endorsement of automatic (intrapersonal) NSSI functions, differing primarily with respect to the level of social (interpersonal) NSSI functions endorsed. Both groups exhibited higher levels of depression, anxiety, BPD symptoms, and suicidality compared to other groups, and were indistinguishable from each other on these constructs (Bracken-​Minor et  al., 2012). Interestingly, these groups differed with respect to alcohol use problems, such that individuals in the group characterized by high levels of intrapersonal and interpersonal functions were more likely to report alcohol use problems and coping, enjoyment and conformity motives for alcohol use. Suicidality was also elevated in a third group, characterized by high levels of intrapersonal NSSI functions and a high prevalence of cutting behavior. The remaining two groups (labeled as “experimental” and “mild”) were the least impaired across all domains. A similar investigation was conducted by Somer and colleagues (2015) using latent class analyses in a large community sample (N = 1656) of Turkish adolescents, identifying four subgroups of youth on the basis of NSSI methods and functions. The group characterized by use of multiple NSSI methods and high endorsement of both intrapersonal and interpersonal NSSI functions exhibited the greatest clinical severity, with high levels of anxiety, depression, hopelessness, alcohol use, suicidal ideation, and suicide attempts. Two classes exhibited more moderate NSSI behaviors, one characterized by cutting and high endorsement of intrapersonal or automatic NSSI functions, and the other by self-​banging or hitting and low endorsement of both types of NSSI functions. These groups did not differ with respect to most constructs assessed, although the group reporting cutting behaviors exhibited higher levels of hopelessness, suicidal ideation, and suicide attempts than the banging/​hitting group. A fourth group was characterized by low levels of all NSSI methods and functions, and the lowest clinical severity on other measures (Somer et al., 2015). This pattern of results is consistent with earlier findings indicating that the use of multiple NSSI methods, rather than frequency of NSSI, is indicative of greater overall clinical severity, even when compared to individuals using a single, prototypical method of NSSI (Turner, Layden, Butler, & Chapman, 2013).These studies also highlight the role of multiple NSSI functions in determining clinical risk in NSSI, particularly with respect to other types of behaviors that could also serve automatic or social functions, such as alcohol use. Greater endorsement of multiple types of NSSI functions may be an important risk marker because it suggests a somewhat “indiscriminate” use of NSSI regardless of context, or because the use of NSSI for multiple functions suggests those needs (e.g., social communication, affect regulation) are not being met through other behaviors. Some additional work has investigated how specific NSSI functions relate to NSSI correlates among adults. In a study of university students reporting early

30  Sarah E. Victor and Angelina Yiu

life trauma exposure, only social positive reinforcement (i.e., use of NSSI to gain a socially relevant outcome, such as peer bonding) was associated with suicidal ideation among self-​injurers, but only automatic negative reinforcement (i.e., use of NSSI to escape or reduce unpleasant internal states) was associated with suicide attempts in this group (Roley-​Roberts, Zielinski, Hurtado, Hovey, & Elhai, 2016). A study of university students recruited from multiple campuses similarly found that suicidal ideation was associated with the use of NSSI to communicate emotions to others; in contrast, suicide plans and suicide attempts were each associated with multiple NSSI functions, both intrapersonal and interpersonal (Paul, Tsypes, Eidlitz, Ernhout, & Whitlock, 2015). In a third study of women with a history of NSSI recruited online, intrapersonal NSSI functions were associated with greater lifetime frequency of NSSI as well as greater intensity of negative affect and interpersonal NSSI functions were associated with interpersonal problems, but not with NSSI frequency or affective intensity (Turner, Chapman, & Layden, 2012). Further, use of NSSI as a method of feeling generation was associated with lack of clarity about one’s emotions, and expressive suppression was associated with multiple NSSI functions. This finding is consistent with ecological momentary assessment (EMA) research, which has shown an association between the use of NSSI to feel something and increased frequency and duration of NSSI thoughts and behaviors in daily life (Selby, Nock, & Kranzler, 2014), suggesting that this specific NSSI function may be associated with more generalized use of NSSI. Taken together, these findings suggest that some functions of NSSI may be tied to specific deficits or difficulties; for example, the use of NSSI for interpersonal functions in the context of interpersonal problems (Turner et al., 2012). The replicated result suggesting that suicidal ideation is associated with social communication functions of NSSI is noteworthy, given the association between suicidal behaviors and automatic NSSI functions described above. It is possible that the circumstances contributing to the use of NSSI for social communication purposes indicate risk for suicidal thoughts, but that these factors do not contribute to the transition from suicidal thoughts to suicidal behaviors. Relatively limited research has focused on specific NSSI methods and/​or NSSI frequency, both within or across methods, as contributors to heterogeneity. In one longitudinal study of adolescents followed for one year, researchers found that high frequency NSSI across multiple methods was associated with a variety of problems for both boys and girls (Bjärehed, Wångby-​Lundh, & Lundh, 2012), yet correlates and consequences of specific NSSI methods also varied by gender. For example, among girls, cutting/​scratching was associated with emotional problems and peer problems, while conduct problems were more common in groups characterized by punching or carving. Among boys, carving was associated with conduct problems as well, but punching was associated with peer problems. Consistent with this work, Kleiman and colleagues (2015) found that frequency of self-​hitting, which may be more common among men, was associated with trait anger but not with emotion

Beyond the Basics  31

dysregulation; in contrast, frequency of other NSSI methods was associated with emotion dysregulation, but not trait anger. Given the variability in functions and outcomes associated with specific methods of NSSI, it is perhaps unsurprising that omnibus measures of NSSI frequency show a less-​clear relationship to relevant constructs of interest, such as suicide. Among university students, for example, NSSI frequency showed a curvilinear relationship with suicidal ideation, plans, and attempts, whereby risk increased as individuals moved from low to moderate NSSI, with odds decreasing after reaching moderate to chronic NSSI (Paul et al., 2015). Although most studies described in this section involve traditional longitudinal designs in which individuals were followed over months or years, some research has also begun to use the intensive longitudinal methods of EMA to evaluate how within-​person changes in thoughts, emotions, or behaviors relate to subsequent changes in likelihood of NSSI thoughts or behaviors over minutes, hours, or days. For example, one study of adults with either BPD or avoidant personality disorder (APD) assessed NSSI urges and behaviors multiple times daily for three weeks (Snir, Rafaeli, Gadassi, Berenson, & Downey, 2015). At the between-​persons level, comparing overall measures across individuals, adults with BPD or APD did not differ in number of NSSI urges or behaviors during EMA, or mean levels of affective/​interpersonal states assessed during EMA to identify implicit or inferred motives for NSSI. At the within-​person level, however, significant quadratic effects for dissociation and perceived rejection/​isolation were found, such that these experiences increased in the minutes or hours prior to NSSI, and then gradually faded over time following NSSI. A similar pattern of changes in avoidant behavior and self-​devaluation was found to surround NSSI acts only for adults with APD; adult participants with BPD did not show this relationship, suggesting that these experiences may serve as risk factors for within-​person changes in NSSI risk only for individuals with elevated social anxiety and/​or social-​evaluative concerns (Snir et al., 2015).

Understanding NSSI Our understanding of NSSI has grown by leaps and bounds within the past few decades. For example, prior research has been crucial in informing our understanding of the functions (e.g., Klonsky, 2009; Klonsky & Glenn, 2009; Turner, Chapman & Layden, 2012), clinical correlates (e.g., Bentley et al., 2015; Cucchi et  al., 2016; Honings et  al., 2016), topography (e.g., Turner, Layden, Butler & Chapman, 2013), and risk for suicide (Hamza, Stewart, & Willoughby, 2012;Victor & Klonsky, 2014) associated with NSSI. More recently, investigators have begun the important tasks of identifying key features of NSSI that make it unique from other mental health conditions, as well as understanding heterogeneity of course and outcome among those who engage in NSSI. Existing evidence points not only to emotion dysregulation broadly, but also to the roles of greater negative mood reactivity, variability and intensity in the clinical

32  Sarah E. Victor and Angelina Yiu

presentation of NSSI, relative to other co-​occurring conditions (Arbuthnott et al., 2015; Smith et al., 2017;Turner et al., 2016). Further, research suggests that NSSI is associated with greater clinical severity, even when compared to other populations with serious mental health conditions or problematic behaviors, such as youth engaged in fire-​setting or alcohol use, adults engaged in indirect self-​harm, recent suicide attempts (Dickstein et al., 2015; Kim et al., 2015a; St. Germain & Hooley, 2012). Finally, interpersonal sensitivity and interpersonal problems appears to be more pronounced in NSSI than in other conditions (Eisenberg et al., 2014;Tanner et al., 2016; Turner et al., 2016). Although these lines of research are crucial for identifying what makes NSSI unique from other mental health conditions, more research is needed, particularly with respect to directly comparing individuals engaging in NSSI with individuals engaging in other types of behaviors that could serve similar functions, such as indirect self-​harm behaviors, substance use, or suicidal behaviors. Research at the within-​person level will be critical to identifying unique and shared predictors of NSSI and other types of concerning behaviors over the course of minutes and hours in daily life. In this chapter, we also highlighted several important lines of research that enhance our understanding of the heterogeneity within NSSI, including the presence, type and severity of adverse life events, the role of culture, and co-​ occurring behaviors that contribute to variability in the course and trajectory of NSSI over time. Research has just begun to identify characteristics of individuals who initiate NSSI, cease NSSI, or continue use of NSSI (Barrocas et al, 2015; Giletta et al., 2015; Law & Shek, 2016; Wang et al., 2016). This work, although useful in differentiating individuals without NSSI from those who engage in any amount of NSSI, has provided limited information about differentiating individuals who engage in moderate to high levels of NSSI. Greater work, therefore, is needed to understand variability in NSSI trajectories among individuals with higher clinical severity and NSSI frequency over time. Research on heterogeneity within NSSI is also crucial to identify those who are at greatest risk for suicide, as NSSI is a risk factor for suicidal behavior, but not all individuals who engage in NSSI will exhibit suicidal behavior in their lifetime. To address this critical question, longitudinal research among high-​risk groups of individuals will be necessary to identify the factors that contribute to the transition from suicidal thoughts to suicidal actions among those with a history of NSSI.

References American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-​5. Washington, DC: American Psychiatric Association. Andrews,T., Martin, G., & Hasking, P. (2012). Differential and common correlates of non-​ suicidal self-​injury and alcohol use among community-​based adolescents. Advances in Mental Health, 11, 55–​66. doi.org/​10.5172/​jamh.2012.2392 Anestis, M. D., Tull, M. T., Lavender, J. M., & Gratz, K. L. (2014). The mediating role of non-​suicidal self-​injury in the relationship between impulsivity and suicidal behavior

Beyond the Basics  33 among inpatients receiving treatment for substance use disorders. Psychiatry Research, 218, 166–​173. doi.org/​10.1016/​j.psychres.2014.03.031 Arbuthnott, A.  E., Lewis, S.  P., & Bailey, H.  N. (2015). Rumination and emotions in nonsuicidal self-​injury and eating disorder behaviors: A preliminary test of the emotional cascade model. Journal of Clinical Psychology, 71, 62–​ 71. doi.org/​ 10.1002/​ jclp.22115 Barrocas, A.  L., Giletta, M., Hankin, B.  L., Prinstein, M.  J., & Abela, J.  R.  Z. (2015). Nonsuicidal self-​injury in adolescence: Longitudinal course, trajectories, and intrapersonal predictors. Journal of Abnormal Child Psychology, 43, 369–​380. doi.org/​10.1007/​ s10802-​014-​9895-​4 Bentley, K. H., Cassiello-​Robbins, C. F., Vittorio, L., Sauer-​Zavala, S., & Barlow, D. H. (2015).The association between nonsuicidal self-​injury and the emotional disorders: A meta-​analytic review. Clinical Psychology Review, 37, 72–​ 88. doi.org/​ 10.1016/​ j.cpr.2015.02.006 Bjärehed, J., Wångby-​Lundh, M., & Lundh, L.  G. (2012). Nonsuicidal self-​injury in a community sample of adolescents: Subgroups, stability, and associations with psychological difficulties. Journal of Research on Adolescence, 22, 678–​693. doi.org/​10.1111/​ j.1532-​7795.2012.00817.x Bracken-​ Minor, K.  L., & McDevitt-​ Murphy, M.  E. (2014). Differences in features of non-​ suicidal self-​ injury according to borderline personality disorder screening status. Archives of Suicide Research, 18, 88–​103. doi.org/​10.1080/​ 13811118.2013.809040 Bracken-​Minor, K. L., McDevitt-​Murphy, M. E., & Parra, G. R. (2012). Profiles of non-​ suicidal self-​injurers and associated patterns of alcohol use. Journal of Psychopathology and Behavioral Assessment, 34, 552–​563. doi.org/​10.1007/​s10862-​012-​9306-​5 Buckholdt, K.  E., Parra, G.  R., Anestis, M.  D., Lavender, J.  M., Jobe-​Shields, L.  E., Tull, M.  T., & Gratz, K.  L. (2014). Emotion regulation difficulties and maladaptive behaviors:  Examination of deliberate self-​ harm, disordered eating, and substance misuse in two samples. Cognitive Therapy and Research, 39, 140–​152. doi.org/​10.1007/​ s10608-​014-​9655-​3 Calati, R., Bensassi, I., & Courtet, P. (2017). The link between dissociation and both suicide attempts and non-​suicidal self-​injury: Meta-​analyses. Psychiatry Research, 251, 103–​114. doi.org/​10.1016/​j.psychres.2017.01.035 Cervantes, R.  C., Goldbach, J.  T., Varela, A., & Santisteban, D.  A. (2014). Self-​harm among Hispanic adolescents: Investigating the role of culture-​related stressors. Journal of Adolescent Health, 55, 633–​639. doi.org/​10/​f6n3vx Calhoun, P. S.,Van Voorhees, E. E., Elbogen, E. B., Dedert, E. A., Clancy, C. P., Hair, L. P., … Kimbrel, N. A. (2017). Nonsuicidal self-​injury and interpersonal violence in U.S. Veterans seeking help for posttraumatic stress disorder. Psychiatry Research, 247, 250–​ 256. doi.org/​10.1016/​j.psychres.2016.11.032 Cucchi, A., Ryan, D., Konstantakopoulos, G., Stroumpa, S., Kaçar, A. Ş., Renshaw, S., … Kravariti, E. (2016). Lifetime prevalence of non-​suicidal self-​injury in patients with eating disorders:  A systematic review and meta-​analysis. Psychological Medicine, 46, 1345–​1358. doi.org/​10.1017/​s0033291716000027 Dickstein, D.  P., Puzia, M.  E., Cushman, G.  K., Weissman, A.  B., Wegbreit, E., Kim, K. L., … Spirito, A. (2015). Self-​injurious implicit attitudes among adolescent suicide attempters versus those engaged in nonsuicidal self-​injury. Journal of Child Psychology and Psychiatry, and Allied Disciplines, 56, 1127–​1136. doi.org/​10.1111/​jcpp.12385

34  Sarah E. Victor and Angelina Yiu Eisenberg, D., Golberstein, E., & Whitlock, J. L. (2014). Peer effects on risky behaviors: New evidence from college roommate assignments. Journal of Health Economics, 33, 126–​138. doi.org/​10.1016/​j.jhealeco.2013.11.006 Eisenberg, D., Hunt, J., & Speer, N. (2013). Mental health in American colleges and universities: Variation across student subgroups and across campuses. The Journal of Nervous and Mental Disease, 201, 60–​67. doi:10.1097/​NMD.0b013e31827ab077 Fox, K. R., Franklin, J. C., Ribeiro, J. D., Kleiman, E. M., Bentley, K. H., & Nock, M. K. (2015). Meta-​analysis of risk factors for nonsuicidal self-​injury. Clinical Psychology Review, 42, 156–​167. doi.org/​10.1016/​j.cpr.2015.09.002 Fox, K. R., Toole, K. E., Franklin, J. C., & Hooley, J. M. (2017). Why does nonsuicidal selfinjury improve mood? A preliminary test of three hypotheses. Clinical Psychological Science, 5(1) 111–​121. doi:10.1177/​2167702616662270 Giletta, M., Prinstein, M. J., Abela, J. R. Z., Gibb, B. E., Barrocas, A. L., & Hankin, B. L. (2015). Trajectories of suicide ideation and nonsuicidal self-​injury among adolescents in mainland China: Peer predictors, joint development, and risk for suicide attempts. Journal of Consulting and Clinical Psychology, 83, 265–​279. doi.org/​10.1037/​a0038652 Goldstein, T. R., Birmaher, B., Axelson, D., Ryan, N. D., Strober, M. A., Gill, M. K., … Keller, M. (2005). History of suicide attempts in pediatric bipolar disorder:  Factors associated with increased risk. Bipolar Disorders, 7, 525–​ 535. doi.org/​ 10.1111/​ j.1399-​5618.2005.00263.x Guan, K., Fox, K.  R., & Prinstein, M.  J. (2012). Nonsuicidal self-​injury as a time-​ invariant predictor of adolescent suicide ideation and attempts in a diverse community sample. Journal of Consulting and Clinical Psychology, 80, 842–​849. doi.org/​ 10.1037/​a0029429 Gratz, K. L., & Gunderson, J. G. (2006). Preliminary data on an acceptance-​based emotion regulation group intervention for deliberate self-​harm among women with Borderline Personality Disorder. Behavior Therapy, 37, 25–​35. doi:10.1016/​j.beth.2005.03.002 Hamza, C.  A., Stewart, S.  L., & Willoughby, T. (2012). Examining the link between nonsuicidal self-​injury and suicidal behavior: A review of the literature and an integrated model. Clinical Psychology Review, 32, 482–​495. doi.org/​10.1016/​j.cpr.2012.05.003 Hamza, C. A., & Willoughby, T. (2013). Nonsuicidal self-​injury and suicidal behavior: A latent class analysis among young adults. PloS ONE, 8, e59955. doi.org/​10.1371/​ journal.pone.0059955 Hamza, C.  A., Willoughby, T., & Heffer, T. (2015). Impulsivity and nonsuicidal self-​ injury:  A review and meta-​analysis. Clinical Psychology Review, 38, 13–​24. doi.org/​ 10.1016/​j.cpr.2015.02.010 Hasking, P., Whitlock, J., Voon, D., & Rose, A. (2016). A cognitive-​emotional model of NSSI: Using emotion regulation and cognitive processes to explain why people self-​ injure. Cognition & Emotion, 31, 1–​14. doi:10.1080/​02699931.2016.1241219 Honings, S., Drukker, M., Groen, R., & van Os, J. (2016). Psychotic experiences and risk of self-​injurious behavior in the general population: A systematic review and meta-​ analysis. Psychological Medicine, 46, 237–​251. doi.org/​10.1017/​s0033291715001841 Horowitz, S., & Stermac, L. (2018). The relationship between interpersonal trauma history and the functions of non-​suicidal self-​injury in young adults:  An experience sampling study. Journal of Trauma & Dissociation, 19, 232–​ 246. doi.org/​ 10.1080/​ 15299732.2017.1330228 Houben, M., Claes, L.,Vansteelandt, K., Berens, A., Sleuwaegen, E., & Kuppens, P. (2017). The emotion regulation function of nonsuicidal self-​injury: A momentary assessment

Beyond the Basics  35 study in inpatients with borderline personality disorder features. Journal of Abnormal Psychology, 126, 89–​95. doi.org/​10/​f9njxc Islam, M.  A., Steiger, H., Jiménez-​Murcia, S., Israel, M., Granero, R., Agüera, Z., … Fernández-​ Aranda, F. (2015). Non-​ suicidal self-​ injury in different eating disorder types: Relevance of personality traits and gender. European Eating Disorders Review, 23, 553–​560. doi.org/​10.1002/​erv.2374 Jarvi, S., Jackson, B., Swenson, L., & Crawford, H. (2013). The impact of social contagion on non-​suicidal self-​injury: A review of the literature. Archives of Suicide Research, 17, 1–​19. doi.org/​10/​gdcg3d Joiner,T. E. (2005).Why people die by suicide. Cambridge, MA: Harvard University Press. Kaess, M., Parzer, P., Mattern, M., Plener, P.  L., Bifulco, A., Resch, F., & Brunner, R. (2013). Adverse childhood experiences and their impact on frequency, severity, and the individual function of nonsuicidal self-​injury in youth. Psychiatry Research, 206, 265–​272. doi.org/​10.1016/​j.psychres.2012.10.012 Kaplan, C., Tarlow, N., Stewart, J.G., Aguirre, B., Galen, G., & Auerbach, R.P. (2016). Borderline personality disorder in youth: The prospective impact of child abuse on non-​suicidal self-​injury and suicidality. Comprehensive Psychiatry, 71, 86–​94. doi.org/​ 10.1016/​j.comppsych.2016.08.016 Kim, K. L., Cushman, G. K., Weissman, A. B., Puzia, M. E., Wegbreit, E., Tone, E. B., … Dickstein, D. P. (2015a). Behavioral and emotional responses to interpersonal stress: A comparison of adolescents engaged in non-​suicidal self-​injury to adolescent suicide attempters. Psychiatry Research, 228, 899–​906. doi.org/​10.1016/​j.psychres.2015.05.001 Kim, K.  L., Galvan, T., Puzia, M.  E., Cushman, G.  K., Seymour, K.  E., Vanmali, R., … Dickstein, D.  P. (2015b). Psychiatric and self-​injury profiles of adolescent suicide attempters versus adolescents engaged in nonsuicidal self-​injury. Suicide & Life-​ Threatening Behavior, 45, 37–​50. doi.org/​10.1111/​sltb.12110 Kleiman, E. M.,Ammerman, B. A., Kulper, D. A., Uyeji, L. L., Jenkins,A. L., & McCloskey, M.  S. (2015). Forms of non-​suicidal self-​injury as a function of trait aggression. Comprehensive Psychiatry, 59, 21–​27. doi.org/​10.1016/​j.comppsych.2014.12.004 Kleindienst, N., Bohus, M., Ludäscher, P., Limberger, M. F., Kuenkele, K., Ebner-​Priemer, U. W., … Schmahl, C. (2008). Motives for nonsuicidal self-​injury among women with Borderline Personality Disorder. The Journal of Nervous and Mental Disease, 196, 230–​ 236. doi:10.1097/​nmd.0b013e3181663026 Klonsky, E. D. (2007). The functions of deliberate self-​injury: A review of the evidence. Clinical Psychology Review, 27, 226–​239. doi.org/​10.1016/​j.cpr.2006.08.002 Klonsky, E.  D. (2009). The functions of self-​injury in young adults who cut themselves: clarifying the evidence for affect-​regulation. Psychiatry Research, 166, 260–​268. doi.org/​10/​d4864s Klonsky, E.  D. & Glenn, C.  G. (2009). Assessing the functions of non-​suicidal self-​ injury:  Psychometric properties of the Inventory of Statements About Self-​injury (ISAS). Journal of Psychopathology and Behavioral Assessment, 31(3), 215–​ 219. doi:10.1007/​s10862-​008-​9107-​z Klonsky, E.  D., Glenn, C.  R., Styer, D.  M., Olino, T.  M., & Washburn, J.  J. (2015). The functions of nonsuicidal self-​injury: Converging evidence for a two-​factor structure. Child and Adolescent Psychiatry and Mental Health, 9, 44. doi: 10.1186/​s13034-​015-​0073-​4 Klonsky, E. D., May, A. M., & Glenn, C. R. (2013). The relationship between nonsuicidal self-​injury and attempted suicide: Converging evidence from four samples. Journal of Abnormal Psychology, 122, 231–​237. doi.org/​10/​f4ntfp

36  Sarah E. Victor and Angelina Yiu Klonsky, E. D., Saffer, B. Y., & Bryan, C. J. (2017). Ideation-​to-​action theories of suicide:  A conceptual and empirical update. Current Opinion in Psychology. 22, 38–​43. doi:10.1016/​j.copsyc.2017.07.020 Kuentzel, J. G., Arble, E., Boutros, N., Chugani, D., & Barnett, D. (2012). Nonsuicidal self-​injury in an ethnically diverse college sample. American Journal of Orthopsychiatry, 82, 291–​7. doi:10.1111/​j.1939-​0025.2012.01167. Lassri, D., Luyten, P., Fonagy, P., & Shahar, G. (2018). Undetected scars? Self-​criticism, attachment, and romantic relationships among otherwise well-​functioning childhood sexual abuse survivors. Psychological Trauma:  Theory, Research, Practice, and Policy, 10, 121–​129. doi.org/​10/​gcvmxf Latzman, R. D., Gratz, K. L.,Young, J., Heiden, L. J., Damon, J. D., & Hight, T. L. (2010). Self-​injurious thoughts and behaviors among youth in an underserved area of the southern United States: Exploring the moderating roles of gender, racial/​ethnic background, and school-​level. Journal of Youth and Adolescence, 39, 270–​280. doi:10.1007/​ s10964-​009-​9462-​4. Law, B.  M.  F., & Shek, D.  T.  L. (2016). A 6-​year longitudinal study of self-​harm and suicidal behaviors among Chinese adolescents in Hong Kong. Journal of Pediatric and Adolescent Gynecology, 29, S38–​48. doi.org/​10.1016/​j.jpag.2015.10.007 Lukas, C.  A., Ebert, D.  D., Fuentes, H.  T., Caspar, F., & Berking, M. (2017). Deficits in general emotion regulation skills:  Evidence of a transdiagnostic factor. Journal of Clinical Psychology, 74, 1017–​1033. doi:10.1002/​jclp.22565 Newman, D. L., Moffitt, T. E., Caspi, A., Magdol, L., Silva, P. A., & Stanton, W. R. (1996). Psychiatric disorder in a birth cohort of young adults: Prevalence, comorbidity, clinical significance, and new case incidence from ages 11 to 21. Journal of Consulting and Clinical Psychology, 64, 552–​562. doi.org/​10.1037/​0022-​006x.64.3.552 Paul, E.,Tsypes,A., Eidlitz, L., Ernhout, C., & Whitlock, J. (2015). Frequency and functions of non-​suicidal self-​injury: Associations with suicidal thoughts and behaviors. Psychiatry Research, 225, 276–​282. doi.org/​10.1016/​j.psychres.2014.12.026 Polanco-​Roman, L., Tsypes, A., Soffer, A., & Miranda, R. (2014). Ethnic differences in prevalence and correlates of self-​harm behaviors in a treatment-​seeking sample of emerging adults. Psychiatry Research, 220, 927–​934. doi.org/​10.1016/​j.psychres.2014.09.017 Roley-​Roberts, M. E., Zielinski, M. J., Hurtado, G., Hovey, J. D., & Elhai, J. D. (2016). Functions of nonsuicidal self-​injury are differentially associated with suicide ideation and past attempts among childhood trauma survivors. Suicide & Life-​threatening Behavior, 47, 450–​460. doi.org/​10.1111/​sltb.12306 Selby, E. A., Nock, M. K., & Kranzler, A. (2014). How does self-​injury feel? Examining automatic positive reinforcement in adolescent self-​injurers with experience sampling. Psychiatry Research, 215, 417–​423. doi.org/​10.1016/​j.psychres.2013.12.005 Seymour, K. E., Jones, R. N., Cushman, G. K., Galvan, T., Puzia, M. E., Kim, K. L., … Dickstein, D. P. (2016). Emotional face recognition in adolescent suicide attempters and adolescents engaging in non-​ suicidal self-​ injury. European Child & Adolescent Psychiatry, 25, 247–​259. doi.org/​10.1007/​s00787-​015-​0733-​1 Smith, K. E., Hayes, N. A., Styer, D. M., & Washburn, J. J. (2017). Emotional reactivity in a clinical sample of patients with eating disorders and nonsuicidal self-​injury. Psychiatry Research, 257, 519–​525. doi:10.1016/​j.psychres.2017.08.014 Snir, A., Rafaeli, E., Gadassi, R., Berenson, K., & Downey, G. (2015). Explicit and inferred motives for nonsuicidal self-​injurious acts and urges in borderline and avoidant personality disorders. Personality Disorders, 6, 267–​277. doi.org/​10.1037/​per0000104

Beyond the Basics  37 Somer, O., Bildik, T., Kabukçu-​Başay, B., Güngör, D., Başay, Ö., & Farmer, R. F. (2015). Prevalence of non-​suicidal self-​injury and distinct groups of self-​injurers in a community sample of adolescents. Social Psychiatry and Psychiatric Epidemiology, 50, 1163–​1171. doi.org/​10.1007/​s00127-​015-​1060-​z St. Germain, S. A., & Hooley, J. M. (2012). Direct and indirect forms of non-​suicidal self-​ injury: Evidence for a distinction. Psychiatry Research, 197, 78–​84. doi.org/​10.1016/​ j.psychres.2011.12.050 Tanner, A., Hasking, P., & Martin, G. (2016). Co-​occurring non-​suicidal self-​injury and firesetting among at-​r isk adolescents: Experiences of negative life events, mental health problems, substance use, and suicidality. Archives of Suicide Research, 20, 233–​249. doi. org/​10.1080/​13811118.2015.1008162 Tschan,T., Peter-​Ruf, C., Schmid, M., & In-​Albon,T. (2017).Temperament and character traits in female adolescents with nonsuicidal self-​injury disorder with and without comorbid borderline personality disorder. Child and Adolescent Psychiatry and Mental Health, 11, 1–​10. doi.org/​10.1186/​s13034-​016-​0142-​3 Turner, B. J., Arya, S., & Chapman, A. L. (2015). Nonsuicidal self-​injury in Asian versus Caucasian university students: Who, how, and why? Suicide & Life-​Threatening Behavior, 45, 199–​216. doi.org/​10.1111/​sltb.12113 Turner, B.  J., Chapman, A.  L., & Layden, B.  K. (2012). Intrapersonal and interpersonal functions of non suicidal self-​injury:  Associations with emotional and social functioning. Suicide and Life-​ Threatening Behavior, 42, 36–​ 55. doi.org/​ 10.1111/​ j.1943-​278x.2011.00069.x Turner, B.  J., Layden, B.  K., Butler, S.  M., & Chapman, A.  L. (2013). How often, or how many ways:  Clarifying the relationship between non-​ suicidal self-​ injury and suicidality. Archives of Suicide Research, 17, 397–​415. doi.org/​10.1111/​ j.1943-​278x.2011.00069.x Turner, B. J.,Yiu, A., Claes, L., Muehlenkamp, J. J., & Chapman, A. L. (2016). Occurrence and co-​occurrence of nonsuicidal self-​injury and disordered eating in a daily diary study:  Which behavior, when? Psychiatry Research, 246, 39–​ 47. doi.org/​ 10.1016/​ j.psychres.2016.09.012 van Geel, M., Goemans, A., & Vedder, P. (2015). A meta-​analysis on the relation between peer victimization and adolescent non-​suicidal self-​injury. Psychiatry Research, 230, 364–​368. doi.org/​10.1016/​j.psychres.2015.09.017 Vaughn, M. G., Salas-​Wright, C. P., Underwood, S., & Gochez-​Kerr, T. (2015). Subtypes of non-​suicidal self-​injury based on childhood adversity. The Psychiatric Quarterly, 86, 137–​151. doi.org/​10.1007/​s11126-​014-​9313-​7 Victor, S.  E., & Klonsky, E.  D. (2014). Correlates of suicide attempts among self-​ injurers:  A meta-​analysis. Clinical Psychology Review, 34, 282–​297. doi.org/​10.1016/​ j.cpr.2014.03.005 Wang, B., You, J., Lin, M. P., Xu, S., & Leung, F. (2016). Developmental trajectories of nonsuicidal self-​injury in adolescence and intrapersonal/​interpersonal risk factors. Journal of Research on Adolescence, 27, 392–​406. doi.org/​10.1111/​jora.12273 Wester, K. L., & Trepal, H. C. (2015). Nonsuicidal self-​injury: Exploring the connection among race, ethnic identity, and ethnic belonging. Journal of College Student Development, 56, 127–​139. doi:10.1353/​csd.2015.001 Whiffen, V.  E., & MacIntosh, H.  B. (2005). Mediators of the link between childhood sexual abuse and emotional distress:  A critical review. Trauma, Violence, & Abuse, 6, 24–​39. doi.org/​10/​crqn9s

38  Sarah E. Victor and Angelina Yiu Whitlock, J., Muehlenkamp, J., Eckenrode, J., Purington, A., Baral Abrams, G., Barreira, P., & Kress, V. (2013). Nonsuicidal self-​injury as a gateway to suicide in young adults. Journal of Adolescent Health, 52, 486–​492. doi.org/​10.1016/​j.jadohealth.2012.09.010 Xin, X., Ming, Q., Zhang, J., Wang,Y., Liu, M., & Yao, S. (2016). Four distinct subgroups of self-​injurious behavior among Chinese adolescents: Findings from a latent class analysis. PloS ONE, 11, e0158609. doi.org/​10.1371/​journal.pone.0158609 Zelkowitz, R.  L., Cole, D.  A., Han, G.  T., & Tomarken, A. J. (2016). The incremental utility of emotion regulation but not emotion reactivity in nonsuicidal self-​injury. Suicide & Life-​Threatening Behavior, 46, 545–​562. doi.org/​10.1111/​sltb.12236

Section II

Emerging Conceptual and Categorical Issues

Chapter 3

Pain and Self-​C riticism A Benefits and Barriers Approach to NSSI Jill M. Hooley and Kathryn R. Fox

Introduction Does self-​injury hurt? Given that NSSI often involves cutting or burning, the answer may seem obvious. But if NSSI does hurt, why do people do it? Why are some people willing to self-​inflict pain, sometimes doing so hundreds of times? In this chapter, we consider these fundamental questions about NSSI. First, we provide a brief overview of pain processing. We then review studies concerning pain perception in NSSI. Following this, we address the issue of whether experiencing pain is important for those who engage in NSSI and discuss the benefits that experiencing pain may provide. We also highlight the importance of self-​ criticism –​a psychological construct that helps explain the selection of NSSI as a mood regulation strategy and that also appears to moderate whether pain is reinforcing. Finally, we consider the clinical implications of these ideas and their potential to provide new directions for NSSI research and treatment.

Physical Pain Perception For most people, pain is an unpleasant subjective experience. It signals threat to body integrity. It also facilitates learning and behavior designed to protect the individual from further harm.This is no doubt important for survival. An unfortunate illustration of this point is provided by people who are born with rare genetic mutations that prevent pain. Unless carefully monitored, such people are at high risk of early death from undetected injuries (Cox et al., 2006; Nagasako, Oaklander, & Dworkin, 2003). Two key components are involved in the experience of physical pain  –​a sensory component and an affective component. The sensory component is involved in localizing pain (arm or leg, left or right, etc.). It also signals the quality of the pain (aching, stabbing, burning) and the strength or intensity of the pain signal. The affective component, in contrast, is involved in coding how distressing or how unpleasant the pain experience is, as well as creating the drive to terminate exposure to the painful experience itself. Many brain areas are involved in pain processing. There is no dedicated or exclusive pain system as such. Rather, the brain areas that are involved belong

42  Jill M. Hooley and Kathryn R. Fox

to different functional systems and become transiently engaged during pain processing. The sensory component of acute pain is processed by the primary and secondary somatosensory cortices S1 and S2, and the posterior insula. The affective component of pain, on the other hand, relies on the dorsal anterior cingulate cortex (dACC) and the anterior insula (Treede, 1999). Brain damage in these areas reduces the unpleasantness of pain without compromising pain localization (Berthier, Starkstein, & Leiguarda, 1988; Foltz & White, 1962). Lesions in S1, S2 or the posterior insula, in contrast, result in deficits processing sensory information, but do not disrupt the affective component of pain processing. In such cases patients can report that certain sensations are unpleasant even when they are not well able to discriminate between stimuli, for example (Greenspan & Winifield, 1992; Ploner, Freund, & Schnitzler, 1999). As Ploner and colleagues (2017) have noted, pain is essentially an integrative phenomenon that results from the interactions between sensory and contextual processes.What this means is that our experience of pain can be modulated by a broad range of factors. If the pain is a means to an end (such as is the case with childbirth, piercing, or tattooing) or brings with it other rewards (such as a win for the team or personal glory) the same level of noxious sensory input that might otherwise create considerable distress can be experienced very differently. Expectancies are also important. For example, when participants are given a placebo that they are told will decrease the unpleasantness of a moderate pain stimulus, they report finding the same level of pain less unpleasant than participants who are not given the placebo. Moreover, these reported differences in pain unpleasantness are paralleled by a downregulation of activity in sensory neural regions (i.e., the posterior insula, S1, and S2; Ellingsen et al., 2013). In another study, participants received a moderate amount of pain but were led to expect more or less pain than they actually received. When moderate pain was administered and participants were expecting a higher level of pain, the moderate pain was rated as less aversive than it was rated when participants thought they would be receiving a lower level of pain (Leknes et  al., 2013). In other words, both expectations and the meaning of pain are of paramount importance. This is essential to keep in mind as we consider the role of pain in NSSI.

Pain and NSSI Most people are deterred by the idea of pain, especially self-​inflicted pain. With respect to NSSI, we can therefore think of pain as creating a natural barrier (see Hooley & Franklin, 2018). To engage in NSSI, this barrier must somehow be overcome. But how might this happen? Some researchers have proposed that analgesia, defined as the inability to feel pain, may be one factor that increases the risk that someone will choose to engage in NSSI (e.g., Nock, 2010). There is no evidence to support the idea that people who engage in NSSI are, as a group, insensitive to pain. However, research does suggest that a substantial proportion of those who engage in NSSI report experiencing little or

Pain and Self-Criticism  43

no pain when engaging in self-​injurious behaviors. For example, in a sample of 89 adolescent psychiatric inpatients with a history of NSSI, 47% reported no pain and 33% reported little pain when engaging in NSSI (Nock, Joiner, Gordon, Lloyd-​Richardson, & Prinstein, 2006). Similarly, in a study with just five participants (Liebenluft et al., 1987) and another study with 30 participants (Bohus et al., 2000), over half reported that they did not experience pain during NSSI engagement. Relatedly, Ammerman and colleagues (2016) asked 997 self-​ injuring participants to rate their subjective pain during NSSI on a 1 = no pain to 4 = severe pain scale. The group mean was 2.2. This is comparable to the mean pain intensity rating of 2.0 reported by Nock et al. (2006) for their participant sample. The available data thus suggest that many people who engage in NSSI do not self-​report high levels of pain during NSSI episodes. Laboratory studies provide further support for the idea that pain processing may be attenuated in people who engage in NSSI. Across a broad range of pain induction methods, findings suggest that, compared to non-​self-​injuring controls, people who engage in NSSI have elevated pain thresholds; in other words, they take longer to report the initial onset of pain. These findings have been consistently demonstrated across a range of pain types, including pressure pain (Glenn, Michel, Franklin, Hooley, & Nock, 2014; Hooley, Ho, Slater, & Lockshin, 2010; St. Germain & Hooley, 2013), heat pain (Schmahl et al., 2006), cold pain (Franklin, Hessel, & Prinstein, 2011; Franklin, Aaron, Arthur, Shorkey, & Prinstein, 2012), and electric shock pain (Weinberg & Klonsky, 2012). Studies further suggest that people who engage in NSSI report higher pain tolerances, taking longer to terminate pain trials compared to non-​self-​injuring controls (Kirtley, O’Carroll, & O’Connor, 2016). One problem with the use of pain tolerance as a dependent variable, however, is that pain tolerance is highly correlated with pain threshold. If someone has a high pain threshold, they are likely to take longer to self-​terminate any given pain trial because it takes them longer to experience the onset of pain. For this reason, Hooley and colleagues (2010) recommended using pain endurance as the key measure. Pain endurance reflects how long someone is willing or able to endure pain once pain is experienced. It is operationalized as pain tolerance minus pain threshold. One advantage of this measure is that it is not confounded by pain threshold. Although there are fewer studies that report this variable, there is clear evidence that pain endurance is elevated in people who engage in NSSI relative to controls who do not self-​injure (Glenn et al., 2014; Hooley et al., 2010; St. Germain & Hooley, 2013). This suggests that once people engaging in NSSI do start to experience pain, they are willing to endure it for much longer than people who do not engage in NSSI. A recent meta-​analysis further confirms the presence of altered pain perception among people who engage in NSSI (Koenig, Thayer, & Kaess, 2016). People engaging in NSSI had higher pain thresholds and tolerances and reported pain as less intense, compared to people without NSSI histories.These

44  Jill M. Hooley and Kathryn R. Fox

effects persisted across ages examined, as well as across genders and clinical diagnoses, although effects were even larger among participants with borderline personality disorder. In summary, research findings suggest that although pain processing appears blunted among people engaging in NSSI, participants do experience some pain during laboratory pain tasks, even if their self-​reported pain during NSSI is often rated as being low in intensity. This is consistent with many people reporting that they actually engage in NSSI so that they can feel pain (e.g., approximately 34% of adolescents who engage in NSSI: Nock & Prinstein, 2004). Indeed, self-​ report studies reveal that experiencing more pain during NSSI is associated with more frequent NSSI engagement (Klonsky & Olino, 2008; Lloyd-​Richardson, Perrine, Dierker, & Kelley, 2007; Nock et  al., 2006; Selby, Nock, & Kranzler, 2014) and use of more NSSI methods (Nock et al., 2006). Research further suggests that among people who engage in NSSI, these sensory deficits are specific to pain. For instance, Pavony and Lenzenweger (2014) found that individuals diagnosed with borderline personality disorder (many of whom engaged in NSSI) displayed increased endurance to cold pain. However, other testing revealed no evidence of more generalized problems in basic touch perception or proprioception (body sense). Like pain perception, these are submodalities of the somatosensory system. Pavony and Lenzenweger’s findings are more consistent with a psychological rather than biological mechanism, as the latter might be expected to create more generalized problems in addition to pain processing abnormalities.

Why Is Pain Perception Aberrant In People Who Engage In NSSI? How should we understand increased pain thresholds and pain endurances among people who engage in NSSI? One possibility is that altered pain perception reflects biological differences between those who engage in NSSI and those who do not. For example, it has been demonstrated that a variant of the μ-​opioid receptor gene (OPRM1) is associated with reduced sensitivity to pressure pain, especially in males (Fillingim et  al., 2005). Genetic variants of the catechol-​O-​methyl transferase (COMT) gene are also thought to be capable of potentially decreasing pain. COMT inhibition has been associated with increased pain sensitivity. Accordingly, high COMT enzymatic activity (which increases the availability of dopamine) may be linked to decreased pain perception. Several other genetic variants found in the general population also reduce pain perception to various degrees (see Oertel & Lötsch, 2008 for a review). Currently, nothing is known about the prevalence of these genetic variants in people who engage in NSSI. However, if people who go on to engage in NSSI are in some ways genetically predisposed to experience less pain, it is curious that they do not also seem to engage in other activities that tend to be painful. For example, we might expect that people who are less pain-​sensitive

Pain and Self-Criticism  45

might be more inclined to enjoy other painful activities, such as contact sports. However, there is little evidence that this is the case (Franklin et al., 2011). Some preliminary evidence also suggests that, following termination of NSSI, there is normalization of and an increase in pain sensitivity (Ludascher et al., 2007). However, in a longitudinal study with adolescents, simple reductions in NSSI frequency did not normalize pain perception (Koenig et al., 2017). Given that both of these studies involved small samples of NSSI participants (24 and 18, respectively), there was limited statistical power to detect reliable effects. At this stage, therefore, we can say little that is definitive about whether pre-​existing pain perception abnormalities predispose some people to engage in NSSI. Although purely biological explanations cannot be ruled out, the psychology of pain perception must also be considered. As we noted at the beginning of this chapter, top-​down processes modulate how pain is perceived. The experience of pain is influenced by attention, emotion, and expectations, as well as by prior experience (Navratilova & Porreca, 2014). Painful stimuli are interpreted, with emotional and cognitive factors playing a role. Moreover, as Bastian and colleagues (2014) have noted, a distinction must be made between nocioception and pain. Nocioception involves the stimulation of nerve fibers sending signals to the brain about the potential for tissue damage. Pain, in contrast, is a subjective perception. Although it is related to an above-​threshold (and variable) level of nocioception, it can also be entirely uncoupled from the level of nerve stimulation that is present. What this means is that pain can sometimes arise in the absence of painful stimulation. Intense nocioception can also sometimes fail to result in an experience of pain. All of this highlights the complexity of pain processing.

Pain and Mood Regulation We do not yet know why people who engage in NSSI report reduced pain perception. Nonetheless, one thing is clear: the majority of people who engage in NSSI, including adults and adolescents, report that doing so helps them to feel better (Taylor et al., 2018). In other words, pain provides them with affective benefits (see Hooley & Franklin, 2018). But why should pain be reinforcing?

Pain as Distraction One mechanism through which pain may improve mood is via distraction. Distraction is known to improve mood in healthy controls and patients alike (Bastian, Jetten, & Fasoli, 2011; Lyubomirsky, Caldwell, & Nolen-​Hoeksema, 1998; Nolen-​Hoeksema & Morrow, 1993). Personal experience also tells us that pain focuses the mind. Recognizing this, some researchers have proposed that pain improves mood for people who engage in NSSI because pain is such a powerful distractor (Briere & Gil, 1998; Brown, Comtois, & Linehan, 2002; Selby, Connell, & Joiner, 2010). As further support for this perspective, proponents of

46  Jill M. Hooley and Kathryn R. Fox

the distraction model point to research demonstrating that people who engage in NSSI have higher levels of emotion reactivity and affective dysregulation than those who do not (Bresin, 2014; Franklin, Lee, Hanna, & Prinstein, 2013a; Nock et al., 2008). Mild and non-​painful distractions (e.g., listening to music, going for a walk) are therefore not thought to provide enough distraction to regulate negative mood (Chapman, Gratz, & Brown, 2006; Selby, Anestis, & Joiner, 2008). Instead, pain –​an extreme form of distraction –​is necessary. Thus, the distraction model has two primary assumptions: (1) people who engage in NSSI experience extreme emotion dysregulation; and (2) pain acts as a powerful form of distraction. Regarding the first assumption, it is certainly the case that people engaging in NSSI self-​report greater emotion dysregulation compared to people who do not engage in this behavior. Combined with the close traditional association between NSSI and borderline personality disorder (which features affect dysregulation as a core characteristic), these findings have led many researchers and clinicians to conclude that affect dysregulation plays a central role in NSSI. However, many recent studies  –​especially experimental and physiological studies –​cast doubt on this conclusion. Although daily diary and experimental studies indicate that individuals who engage in NSSI tend to report higher levels of negative affect, this negative affect appears to be primarily due to high levels of self-​dissatisfaction (Victor & Klonsky, 2014). Moreover, despite self-​ reporting greater emotion dysregulation and reactivity, experimental studies examining changes in negative affect before, during, and after stressors, across self-​report and psychophysiological measures of affect dysregulation (e.g., startle eyeblink reactivity, heart rate, cortisol), find no differences between those with and without NSSI histories (Bresin & Gordon, 2013; Franklin et  al., 2010; Glenn, Blumenthal, Klonsky, & Hajcak, 2011; Kaess et al., 2012). In other words, although the idea that NSSI is characterized by marked affective dysregulation is intuitively appealing, research has revealed this approach to understanding NSSI to have a number of shortcomings (see Hooley & Franklin, 2018).This calls into question the idea that pain (as an extreme form of distraction) is needed to provide mood regulation benefits. Regarding the second assumption, there is little to no evidence that powerful distraction is needed to improve mood among people who engage in NSSI. Fox and colleagues (2017) have demonstrated that a mild, cognitively engaging neutral distraction repaired mood for people with a past year history of NSSI who were exposed to a negative mood induction. In contrast, participants who experienced pain after the negative mood induction did not show overall evidence of mood repair.This suggests that non-​painful distraction can repair mood among people engaging in NSSI, and pain may not function as a simple distraction. In other words, neither of the assumptions of the distraction hypothesis (that people engaging in NSSI experience extreme emotion dysregulation or that an extreme form of distraction such as pain is needed to help repair mood among people engaging in NSSI) are supported by current research.

Pain and Self-Criticism  47

Pain Offset Relief The findings of Fox et al. (2017) suggest that the distracting aspects of pain may not be the primary means through which NSSI improves mood. But if distraction does not explain why people feel better after engaging in NSSI, what does? Pain offset relief may provide a potential answer. Experiencing pain is unpleasant; the termination of pain is welcome. A large body of research supports the idea that the removal of pain is an important facilitator of mood improvement.This pain offset relief effect has been examined in basic pain studies for several decades. It has been demonstrated in healthy humans, in rats, and even in fruit flies (Gerber et al., 2014). Pain offset relief occurs automatically and requires no learning or conditioning (Franklin et  al., 2013b). Pain offset relief also occurs in the absence of affect dysregulation or elevated negative mood. Following the removal of pain, negative affect and physiological arousal are significantly reduced and positive affect is increased (Bastian, Jetten, Hornsey, & Leknes, 2014; Franklin et  al., 2013b; Gerber et al., 2014). In other words, pain –​or more specifically the termination of pain  –​provides benefits. These benefits involve both positive and negative reinforcement. In NSSI groups, across a range of self-​report and physiological measures, laboratory studies show that mood also improves after painful stimuli (Bresin & Gordon, 2013; Franklin et al., 2010, 2013; Schoenleber, Berenbaum, & Motl, 2014; Weinberg & Klonsky, 2012). Importantly, however, and contrary to what many clinicians believe, this effect is not specific to those who engage in NSSI. With few exceptions, these studies show that pain-​induced mood regulation in the NSSI groups is not significantly different from that observed in the control groups. Pain offset relief offers one mechanism through which NSSI may provide short-​term affective benefits. But why does the offset of physical pain bring about emotional benefits? Earlier we noted that physical pain activates the anterior cingulate cortex and the anterior insula. These same areas are also activated during emotional pain such as that caused by social rejection. In other words, there is a common neural overlap between physical and emotional pain (see Eisenberger, 2012, 2015; Franklin et  al., 2013b). One consequence of this is that factors that affect physical pain incidentally affect emotional pain. Reflecting this, acetaminophen (a commonly used physical painkiller known to most of us as Tylenol) has been shown to reduce the emotional pain that results from a social exclusion manipulation. It is also interesting to note that this effect is mediated in part by anterior cingulate and anterior insula activity (DeWall et al., 2010). Of course, as we all know, emotional pain is difficult to control. However, self-​induced physical pain may provide a means to access pain neurocircuitry, replacing emotional pain with physical pain. When the painful stimulus is terminated, pain offset relief brings affective benefits, reducing negative mood and increasing positive mood. Over time, it is perhaps not difficult to see how

48  Jill M. Hooley and Kathryn R. Fox

this might create a desire to use NSSI as a form of mood regulation. Consistent with this perspective, there is evidence that, the more people engage in NSSI, the more mood benefits they report obtaining from a given episode of NSSI (Gordon et al., 2010).

Self-​C riticism Until relatively recently, NSSI was generally considered to be a symptom of borderline personality disorder. Although this is still true, we now understand that NSSI is more transdiagnostic in nature (Bentley, Cassiello-​Robbins, Vittorio, Sauer-​Zavala, & Barlow, 2015). It is also increasingly clear that emotional dysregulation is not a major hallmark of people who engage in NSSI, although when NSSI occurs in samples containing a high level of borderline personality pathology, affective dysregulation is much more prominent (Houben et al., 2017; Santangelo et al., 2016). Nonetheless, regardless of the level of emotional reactivity that is associated with NSSI, it is clear that it is being used to regulate affect. This raises a key question: Why? We all need to regulate our moods. Given all the other choices available (talking to a friend, having a glass of wine, going for a run), why do some people chose to regulate their negative mood by cutting or burning themselves? And if NSSI provides the affective benefits we have just described, what stops most people from trying it? One possible explanation relates to self-​concept. People who engage in NSSI report higher levels of self-​criticism (Glassman, Weierich, Hooley, Deliberto, & Nock, 2007; Hooley et al., 2010; St. Germain & Hooley, 2012) as well as negative self-​views (Weismoore & Esposito-​Smythers, 2010) and self-​dissatisfaction (Victor & Klonsky, 2014) compared to people who do not engage in NSSI. Moreover, in those with a history of NSSI, self-​criticism is positively associated with greater past NSSI engagement (Fox, Toole, Franklin, & Hooley, 2017) as well as future NSSI engagement (Fox et al., 2018). Why is this important? Self-​punishment is often cited as a reason for engaging in NSSI. Although not as commonly cited as emotion regulation, a review showed that across 113 studies, 72 found that self-​punishment is often endorsed as a reason for engaging in NSSI (Edmondson, Brennan, & House, 2016). Relevant here is that self-​criticism is significantly associated with endorsing self-​ punishment as a motivator for engaging in NSSI (Glassman et al., 2007). Further, a growing body of research suggests that the desire to self-​punish may be an important factor influencing the decision to self-​inflict pain.

Self-​C riticism and Pain Self-​criticism and pain are linked in an important way. More specifically, self-​ criticism is significantly associated with pain endurance –​the amount of time someone is willing to endure pain. This was initially observed by Hooley and

Pain and Self-Criticism  49

colleagues (2010). The finding has since been replicated in adults (Fox et  al., 2017; Hooley & St. Germain, 2014) and adolescents (Glenn et al., 2014) using pressure pain. Moreover, endorsing self-​punishment as an NSSI motivator is associated with increased pain tolerance and with rating pain as less aversive (Hamza, Willoughby, & Armiento, 2014). Why should self-​criticism and associated self-​punishing motivations predict greater pain endurance? Pain may provide unique emotional benefits for people who are highly self-​critical because pain may be perceived as something that is deserved (see Hooley et al., 2010; Hooley & St. Germain, 2014; St. Germain & Hooley, 2012). People who feel that they are bad, worthless, or toxic may seek out pain because experiencing pain is ego-​syntonic and self-​affirming. It also provides a method of atonement. This may explain why people who engage in NSSI are willing to endure pain for longer. We know that when college students are made to feel guilty, they report significantly less guilt after completing a pain task (Bastian, Jetten, & Fasoli, 2011). Additionally, in a sample of female adults with and without NSSI histories, a pain induction significantly reduced self-​reported shame (Schonleber et  al., 2014). This suggests that the experience of pain, as we have already noted, is regulating mood. But how is this mood regulation occurring? In the two studies just mentioned, mood changes were only assessed at the end of the pain task; no mood assessment occurred during the experience of pain itself. This makes it hard to know whether the reported changes in guilt and shame were due to general reductions in negative mood that resulted from pain offset relief, or whether mood benefits occurred because of the gratification of self-​punishment desires via pain. Fox and colleagues (2017) recently examined this issue in a sample of participants who reported past year NSSI engagement. As described earlier, some participants in this study were randomly assigned to experience pressure pain. Ratings of mood taken before, during, and after the pain task revealed no evidence of mood change from experiencing pain overall. However, the findings showed that participants who scored high on self-​criticism experienced mood improvements during pain, whereas those participants lower in self-​criticism experienced all mood improvements upon the removal of pain. In other words, self-​criticism was an important moderator. For people who are highly self-​ critical, the experience of pain is rewarding. For those lower in self-​criticism, in contrast, the removal of pain is rewarding. What this means is that both self-​ punishment and pain offset relief are of central importance in understanding why pain provides affective benefits to those who engage in NSSI. For those high on self-​criticism, pain may be rewarding because it is experienced as something that is deserved. For those who are lower on self-​criticism, the mood benefits of pain offset relief may be more salient. If pain provides mood benefits for people who are highly self-​critical, we might expect that making people who engage in NSSI feel better about themselves would reduce these benefits, decreasing the amount of time they are willing to

50  Jill M. Hooley and Kathryn R. Fox

endure pain. In an experimental test of this hypothesis, Hooley and St. Germain (2014) developed a “positive self-​worth” intervention targeting self-​criticism. This specific intervention had two main parts. Participants first read and selected positive traits or characteristics that they felt applied to them from a list of 21 positive character traits (e.g., kind, insightful, loyal). Those who were not able to select any positive traits were told to think instead what a friend or relative would say of them. Next, with the help of a trained interviewer, participants were asked to elaborate on a time that they embodied one of these traits. Compared to a positive and neutral mood induction, this positive self-​worth intervention substantially decreased pain endurance among people with a history of NSSI. Pain endurance decreased on average by 69 seconds among those who underwent this intervention, compared to an average 9-​second reduction in non-​self-​ injuring controls. The finding that pain endurance could be reduced by almost 50% in NSSI participants using a very brief (5 minutes) cognitive intervention is important for several reasons. First, it suggests a novel and specific treatment target for those who engage in NSSI. Second, it highlights the role of psychological factors (e.g., sense of self) in understanding pain processing in NSSI. As we noted at the beginning of this chapter, the meaning of pain plays a central role in determining how pain is perceived and how it is responded to. For those who engage in NSSI, the meaning of pain is very different than it is for those who do not engage in this behavior.

Summary A cognitive style that involves high self-​criticism or self-​hatred may be important for understanding NSSI. We believe it is a specific risk factor for the development of NSSI. This is because high self-​criticism or self-​hatred removes a potential barrier to self-​injury. It does this by allowing the person to consider strategies for emotion regulation such as cutting that other people (who value themselves and their bodies much more) would immediately reject. People who hold core beliefs about being bad, flawed, or defective may therefore have less resistance to the idea of NSSI than people who have self-​schemas that are more benign. Moreover, once people try NSSI, they learn something that is important and problematic. What they learn is that self-​injury works. Self-​injury improves mood, providing both affective and cognitive benefits. Pain is a key component of NSSI experience. Pain appears to be reinforcing through pain offset relief and self-​punishment mechanisms. Pain offset relief appears to be universal and is likely related to the activation of reward circuitry in the brain (Leknes, Lee, Berna, Andersson, & Tracey, 2011; Leknes et al., 2013) and possibly the release of endogenous opioids (Smith & Berridge, 2007; Zubieta et al., 2001, 2002). Mood improvement via self-​punishment appears specific to those with elevated self-​criticism, shame, or guilt. Moreover, although we are highlighting the role of a cognitive factor here, it should be remembered that cognition is a brain-​related event with biological consequences. Reward and

Pain and Self-Criticism  51

reward expectations that come from engaging in an identity affirming behavior (punishing one’s bad self) likely play a key role. If pain brings emotional rewards, we might expect that people with a past history of NSSI will, over time, come to regard pain as a conditioned stimulus for this emotional relief. This may change how they experience pain and how aversive pain is for them. Increased pain thresholds and pain endurances may be the expected result. Relevant here is the finding that adolescents with longer histories of NSSI report feeling less pain when engaging in the act (Claes, Vandereycken, & Vertommen, 2006). This may perhaps reflect the product of expectations and conditioning. There is also no evidence that increased pain endurance is specific to NSSI. St. Germain and Hooley (2013) have shown that people who engage in indirect forms of self-​injury such as abusing drugs or alcohol, staying in abusive relationships, or depriving themselves of food also show increased pain endurance relative to controls.The same is true for people who have thought seriously about engaging in NSSI but have not actually engage in directly self-​injurious behavior of any kind (see Hooley et  al., 2010). In both of these cases, the common factor appears to be self-​criticism (see St. Germain & Hooley, 2012).

Clinical Implications With therapy, NSSI tends to gradually resolve over time, even if it is not a specific focus of attention. This may be because, directly or indirectly, most therapists seek to help their patients develop a healthier sense of self and enhanced levels of self-​worth. However, more NSSI-​specific interventions are still very much needed. Self-​schemas of defectiveness and shame might provide potent treatment targets. As we have noted elsewhere (Hooley & Franklin, 2018), we believe that reinstating barriers to NSSI (for example, by addressing issues of self-​criticism and self-​hatred) may be a more effective approach than trying to decrease the benefits associated with NSSI. This is because the mood-​regulating benefits of NSSI appear to be universal. Trying to block these benefits directly may therefore be challenging. To date, four approaches based on the ideas presented here have been utilized. As mentioned earlier, Hooley and St. Germain (2014) reduced pain endurance by 50% in NSSI participants using a brief cognitive intervention designed to activate positive self-​schemas. Decreasing the mood benefits obtained during pain via reduction of self-​criticism may therefore be one approach that warrants further consideration. Replicating and extending this work, more recent research by Gregory, Glazer, and Berenson (2017) involved an intervention aimed at increasing self-​ compassion among participants with and without self-​injury (not just NSSI) histories. Rather than asking participants to talk about a time they embodied a specific positive trait (which was the approach adopted by Hooley & St. Germain,

52  Jill M. Hooley and Kathryn R. Fox

2014), participants in this study were asked to rank-​order six values in terms of personal importance. They were then required to write an essay describing why their top-​ranked value was important to them. Prior research has shown that this type of intervention can specifically increase self-​compassion (Lindsay & Creswell, 2014). Again, those who completed this intervention, compared to a control intervention where participants wrote about why someone else might value their lowest-​rated value, demonstrated significantly lower pain endurance. This type of intervention may be more effective for people who engage in NSSI, who tend to be highly self-​critical, as there is some evidence that trying to improve self-​perception by focusing on positive qualities can be challenging for people with low self-​esteem, potentially making them feel worse. Targeting self-​compassion instead may be an indirect way of decreasing self-​criticism and willingness to self-​inflict pain. Another indirect approach is to use conditioning methods.These can be used to increase aversion to NSSI stimuli, which, by virtue of being paired with the positive and negative reinforcement that comes from pain and pain offset, can become conditioned stimuli for reward over time. In a group of individuals with a history of NSSI, Franklin et al. (2013b) paired NSSI stimuli with electric shock. Another (control) NSSI group received the same number of shocks and also saw the same NSSI stimuli. However, these were presented without there being any contingency between the NSSI stimuli and the shock. Compared to the control group, there was more than a 50% reduction in NSSI stimuli plus contingent shock group during a six-​month period even after controlling for NSSI rates in the six months prior to the conditioning trials. Additional analyses also revealed that the treatment effect was partially mediated by increased aversion to the NSSI stimuli. More recently, Franklin and colleagues (2016) tested a novel intervention that involved a mobile app.This was designed to use an evaluative conditioning paradigm to target both diminished aversion to NSSI stimuli and self-​criticism in participants who had engaged in self-​cutting at least twice in the prior month. Compared to a control group who received a similar mobile app that only included neutral stimuli, the results showed that the treatment group displayed significant reductions (around 35–​45%) in NSSI over the course of one month. This was true even after controlling for such factors as prior month NSSI, emotion dysregulation, and treatment history. The treatment effect was also associated with increased aversion to NSSI stimuli as well as increased positive associations with the self. Preliminary findings from treatment approaches based on the enhancing self-​worth and self-​compassion or re-​establishing aversion to NSSI stimuli thus show considerable promise.

Concluding Remarks and Future Perspectives Although we have highlighted the importance of self-​ criticism and self-​ punishment motivations for understanding NSSI, other factors are also

Pain and Self-Criticism  53

important. We do not believe that everyone who is inclined to NSSI is invariably highly self-​critical. Other potential routes to NSSI such as desire for peer affiliation (Prinstein et  al., 2010) also warrant consideration. Moreover, as we noted earlier, expectations matter. Having a friend who reports that self-​inflicted pain via NSSI feels good or helps to improve mood may create a context for reduced pain perception. We also need to learn much more about the origins of highly negative attitudes toward the self. Additional insights into how pain perception and self-​criticism (and their biological correlates) might change as a consequence of repeated exposure and habituation to painful acts are also essential. This highlights the importance of longitudinal research. Reducing NSSI in people with longstanding histories of NSSI is likely to be especially challenging. This is because such people have directly experienced and learned about the rewarding aspects of this behavior. They are also likely to have established views of the self that are highly negative and self-​critical. All of this further highlights the need for prevention. Going forward, the potential of preventive efforts designed to enhance self-​worth in adolescents should be evaluated. NSSI in adolescents is an area of increasing clinical concern. The more we can target major risk factors, the more we may be able to prevent the emotional pain that, sadly, is made tangible through self-​injurious behaviors.

References Ammerman, B. A., Burke, T. A., Alloy, L. B. & McClosky, M. S. (2016). Subjective pain during NSSI as an active agent in suicide risk. Psychiatry Research, 236, 80–​85. Bastian, B., Jetten, J., & Fasoli, F. (2011). Cleansing the soul by hurting the flesh:  The guilt-​reducing effect of pain. Psychological Science, 22(3), 334. Bastian, B., Jetten, J., Hornsey, M. J. & Leknes, S. (2014). The positive consequences of pain: A biosocial approach. Personality and Social Psychology Review, 18, 256–​279. Bentley, K. H., Cassiello-​Robbins, C. F., Vittorio, L., Sauer-​Zavala, S., & Barlow, D. H. (2015).The association between nonsuicidal self-​injury and the emotional disorders: A meta-​analytic review. Clinical Psychology Review, 37, 72–​88. Berthier, M., Starkstein, M. D., & Leiguarda, R. (1988). Asymbolia for pain: A sensory–​ limbic disconnection syndrome. Annals of Neurology, 24, 41–​49. Bohus, M., Limberger, M., Ebner, U., Glocker, F., Schwarz, B., Wernz, M., & Lieb, K. (2000). Pain perception during self-​reported distress and calmness in patients with borderline personality disorder and self-​mutilating behavior. Psychiatry Research, 95(3), 251–​260. doi:10.1016/​S0165-​1781(00)00179-​7 Briere, J., & Gil, E. (1998). Self-​ mutilation in clinical and general population samples: Prevalence, correlates, and functions. American Journal of Orthopsychiatry, 68(4), 609–​620. Bresin, K. (2014). Five indices of emotion regulation in participants with a history of nonsuicidal self-​injury: A daily diary study. Behavior Therapy, 45(1), 56–​66. Bresin, K., & Gordon, K.  H. (2013). Changes in negative affect following pain (vs. nonpainful) stimulation in individuals with and without a history of nonsuicidal self-​ injury. Personality Disorders: Theory, Research, and Treatment, 4(1), 62–​66.

54  Jill M. Hooley and Kathryn R. Fox Brown, M. Z., Comtois, K. A., & Linehan, M. M. (2002). Reasons for suicide attempts and nonsuicidal self-​injury in women with borderline personality disorder. Journal of Abnormal Psychology, 111(1), 198. Chapman, A. L., Gratz, K. L., & Brown, M. Z. (2006). Solving the puzzle of deliberate self-​harm:  The experiential avoidance model. Behavior Research and Therapy, 44(3), 371–​394. Claes, L., Vandereycken, W., & Vertommen, H. (2006). Pain experience related to self-​ injury in eating disorder patients. Eating Behaviors, 7(3), 204–​213. Cox, J.  J., Reimann, F., Nicholas, A.  K., Thornton, G., Roberts, E., Springell, K., … Woods, C. G. (2006). An SCN9A channelopathy causes congenital inability to experience pain. Nature, 444(14), 894–​898, doi:10.1038/​nature05413 DeWall, C. N., MacDonald, G., Webster, G. D., Masten, C. L., Baumeister, R. F., Powell, C., … Eisenberger, N. I. (2010). Acetaminophen reduces social pain behavioral and neural evidence. Psychological Science, 21, 931–​937. Edmondson, A. J., Brennan, C. A., & House, A. O. (2016). Non-​suicidal reasons for self-​ harm: A systematic review of self-​reported accounts. Journal of Affective Disorders, 191, 109–​117. Eisenberger, N.  I. (2012). The pain of social disconnection:  Examining the shared neural underpinnings of physical and social pain. Nature Reviews Neuroscience, 13(6), 421–​434. Eisenberger, N. I. (2015). Social pain and the brain: Controversies, questions, and where to go from here. Annual Review of Psychology, 66, 601–​629. Ellingsen, D. M., Wessberg, J., Eikemo, M., Liljencrantz, J., Endestad, T., Olausson, H., & Leknes, S. (2013). Placebo improves pleasure and pain through opposite modulation of sensory processing. Proceedings of the National Academy of Sciences of the United States of America, 110(44), 17993–​17998. doi:10.1073/​pnas.1305050110. Fillingim, R.  B., Kaplan, L., Staud, R., Ness, T.  J., Glover, T.  L., Campbell, C.  M., … Wallace, M. R. (2005). The A118G single nucleotide polymorphism of the μ-​opioid receptor gene (OPRM1) is associated with pressure pain sensitivity in humans. The Journal of Pain, 6(3), 159–​167. Foltz, E.  L. & White, L.E. (1962). Pain “relief ” by frontal cingulumotomy. Journal of Neurosurgery, 19, 89–​100. Fox, K.  R., Ribeiro, J.  D., Kleiman, E.  M., Hooley, J.  M., Nock, M.  C., & Franklin, J. C. (2018). Affect toward the self and self-​injury stimuli as potential risk factors for nonsuicidal self-​injury. Psychiatry Research, 260, 279–​285. Fox, K. R., Toole, K. E., Franklin, J. C., & Hooley, J. M. (2017). Why does self-​injury improve mood? A  preliminary test of three hypotheses. Clinical Psychological Science, 5(1), 111–​121. Franklin, J.  C., Aaron, R.  V., Arthur, M.  S., Shorkey, S.  P., & Prinstein, M.  J. (2012). Nonsuicidal self-​ injury and diminished pain perception:  The role of emotion dysregulation. Comprehensive Psychiatry, 53(6), 691–​ 700. doi:10.1016/​ j.comppsych.2011.11.008 Franklin, J. C., Fox, K. R., Franklin, C. R., Kleiman, E. M., Ribeiro, J. D., Jaroszewski, A. C., … Nock, M. K. (2016). A brief mobile app reduces nonsuicidal and suicidal self-​injury: Evidence from three randomized controlled trials. Journal of Consulting and Clinical Psychology, 84(6), 544–​557. Franklin, J.  C., Hessel, E.  T., Aaron, R.  V., Arthur, M.  S., Heilbron, N., & Prinstein, M. J. (2010). The functions of nonsuicidal self-​injury: Support for cognitive-​affective

Pain and Self-Criticism  55 regulation and opponent processes from a novel psychophysiological paradigm. Journal of Abnormal Psychology, 119(4), 850–​862. doi:10.1037/​a0020896. Franklin, J. C., Hessel, E. T., & Prinstein, M. J. (2011). Clarifying the role of pain tolerance in suicidal capability. Psychiatry Research, 189(3), 362–​367. Franklin, J. C., Lee, K. M., Hanna, E. K., & Prinstein, M. J. (2013a). Feeling worse to feel better pain-​offset relief simultaneously stimulates positive affect and reduces negative affect. Psychological Science, 24(4), 521–​529. Franklin, J.  C., Puzia, M.  E., Lee, K.  M., Lee, G.  E., Hanna, E.  K., Spring, V.  L., & Prinstein, M. J. (2013b). The nature of pain offset relief in nonsuicidal self-​injury: A laboratory study. Clinical Psychological Science, 1(2), 110–​119. Gerber, B., Yarali, A., Diegelmann, S., Wotjak, C.T., Pauli, P., & Fendt, M. (2014). Pain-​ relief learning in flies, rats, and man: Basic research and applied perspectives. Learning and Memory, 21, 232–​252. Glassman, L. H., Weierich, M. R., Hooley, J. M., Deliberto, T. L., & Nock, M. K. (2007). Child maltreatment, non-​suicidal self-​injury, and the mediating role of self-​criticism. Behavior Research and Therapy, 45(10), 2483–​2490. Glenn, C. R., Blumenthal,T. D., Klonsky, E. D., & Hajcak, G. (2011). Emotional reactivity in nonsuicidal self-​ injury:  Divergence between self-​ report and startle measures. International Journal of Psychophysiology, 80(2), 166–​170. Glenn, J. J., Michel, B. D., Franklin, J. C., Hooley, J. M., & Nock, M. K. (2014). Pain analgesia among adolescent self-​injurers. Psychiatry Research, 220, 921–​926. Gordon, K. H., Selby, E. A., Anestis, M. D., Bender,T. W.,Witte,T. K., Braithwaite, K. A., … Joiner, T. E. (2010). The reinforcing properties of deliberate self-​harm. Archives of Suicide Research, 14, 329–​341. Greenspan, J.  D., & Winifield, J. (1992). Reversible and tactile deficits associated with a cerebral tumor compressing the posterior insula and parietal operculum. Pain, 50,  29–​29. Gregory, W. E., Glazer, J. V., & Berenson, K. R. (2017). Self-​compassion, self-​injury, and pain. Cognitive Therapy and Research, 41(5), 777–​786. Hamza, C. A., Willoughby, T., & Armiento, J. (2014). A laboratory examination of pain threshold and tolerance among nonsuicidal self-​ injurers with and without self-​ punishing motivations. Archives of Scientific Psychology, 2(1), 33–​42. Hooley, J. M. & Franklin, J. C. (2018).Why do people hurt themselves? A new conceptual model of nonsuicidal self-​injury. Clinical Psychological Science, 6(3), 428–​451. Hooley, J. M., Ho, D. T., Slater, J., & Lockshin, A. (2010). Pain perception and nonsuicidal self-​injury. Personality Disorders: Theory, Research, and Treatment, 1(3), 170–​179. Hooley, J.  M., & St. Germain, S.  A. (2014). Nonsuicidal self-​injury, pain, and self-​ criticism: Does changing self-​worth change pain endurance in people who engage in self-​injury? Clinical Psychological Science, 2(3), 297–​305. Houben, M., Claes, L.,Vansteelandt, K., Berens, A., Sleuwaegen, E., & Kuppens, P. (2017). The emotion regulation function of nonsuicidal self-​injury: A momentary assessment study in inpatients with borderline personality disorder features. Journal of Abnormal Psychology, 126(1), 89. Kaess, M., Hille, M., Parzer, P., Maser-​ Gluth, C., Resch, F., & Brunner, R. (2012). Alterations in the neuroendocrinological stress response to acute psychosocial stress in adolescents engaging in nonsuicidal self-​injury. Psychoneuroendocrinology, 37(1), 157–​161. Kirtley, O. J., O’Carroll, R. E., & O’Connor, R. C. (2016). Pain and self-​harm: A systematic review. Journal of Affective Disorders, 203, 347–​363.

56  Jill M. Hooley and Kathryn R. Fox Koenig, J., Rinnewitz, L., Niederbäumer, M., Strozyk,T., Parzer, P., Resch, F., & Kaess, M. (2017). Longitudinal development of pain sensitivity in adolescent non-​suicidal self-​ injury. Journal of Psychiatric Research, 89, 81–​84. Koenig, J., Thayer, J. F., & Kaess, M. (2016). A meta-​analysis on pain sensitivity in self-​ injury. Psychological Medicine, 46(8), 1597–​1612. Klonsky, E. D., & Olino, T. M. (2008). Identifying clinically distinct subgroups of self-​ injurers among young adults: A latent class analysis. Journal of Consulting and Clinical Psychology, 76(1), 22–​27. Leibenluft, E., Gardner, D. L., & Cowdry, R. W. (1987).The inner experience of the borderline self-​mutilator. Journal of Personality Disorders, 1(4), 317–​324. doi:10.1521/​ pedi.1987.1.4.317 Leknes, S., Berna, C., Lee, M.  C., Snyder, G.  D., Biele, G., & Tracey, I. (2013). The importance of context:  When relative relief renders pain pleasant. Pain, 154(3), 402–​410. Leknes, S., Lee, M., Berna, C.,Andersson, J., & Tracey, I. (2011). Relief as a reward: hedonic and neural responses to safety from pain. PloS ONE, 6(4), e17870. Lloyd-​Richardson, E. E., Perrine, N., Dierker, L., & Kelley, M. L. (2007). Characteristics and functions of non-​ suicidal self-​ injury in a community sample of adolescents. Psychological Medicine, 37(8), 1183–​1192. Lindsay, E.  K., & Creswell, J.  D. (2014). Helping the self help others:  Self-​affirmation increases self-​compassion and pro-​social behaviors. Frontiers in Psychology, 12 May 2014. https://​doi.org/​10.3389/​fpsyg.2014.00421 Ludäscher, P., Bohus, M., Lieb, K., Philipsen, A., Jochims, A., & Schmahl, C. (2007). Elevated pain thresholds correlate with dissociation and aversive arousal in patients with borderline personality disorder. Psychiatry Research, 149(1–​3), 291–​296. doi:10.1016/​j.psychres.2005.04.009 Lyubomirsky, S., Caldwell, N. D., & Nolen-​Hoeksema, S. (1998). Effects of ruminative and distracting responses to depressed mood on retrieval of autobiographical memories. Journal of Personality and Social Psychology, 75(1), 166. Nagasako, E., M., Oaklander, A. L., & Dworkin, R. H. (2003). Congenital insensitivity to pain: An update. Pain, 101, 213–​219. Navratilova, E., & Porreca, F. (2014). Reward and motivation in pain and pain relief. Nature Neuroscience, 17, 10, 1304–​1312. Nock, M. K. (2010). Self-​injury. Annual Review of Clinical Psychology, 6, 339–​363. Nock, M. K., Joiner Jr, T. E., Gordon, K. H., Lloyd-​Richardson, E., & Prinstein, M. J. (2006). Non-​suicidal self-​injury among adolescents: Diagnostic correlates and relation to suicide attempts. Psychiatry Research, 144(1), 65–​72. Nock, M.  K., & Prinstein, M.  J. (2004). A functional approach to the assessment of selfmutilative behavior. Journal of Consulting and Clinical Psychology, 72(5), 885–​890. doi:10.1037/​0022-​006X.72.5.885 Nock, M.  K., Wedig, M.  M., Holmberg, E.  B., & Hooley, J.  M. (2008). The Emotion Reactivity Scale: Development, evaluation, and relation to self-​injurious thoughts and behaviors. Behavior Therapy, 39(2), 107–​116. doi:10.1016/​j.beth.2007.05.005 Nolen-​Hoeksema, S., & Morrow, J. (1993). Effects of rumination and distraction on naturally occurring depressed mood. Cognition and Emotion, 7(6), 561–​570. Oertel, B., & Lötsch, J. (2008). Genetic mutations that present pain:  Implications for future pain medication. Pharmacogenomics, 9, 179–​194.

Pain and Self-Criticism  57 Pavony, M. T., & Lenzenweger, M. F. (2014). Somatosensory processing and borderline personality disorder features: A signal detection analysis of proprioception and exteroceptive sensitivity. Journal of Personality Disorders, 27(2), 208–​221. Ploner, M., Freund, H. J., & Schnitzler, A. (1999). Pain affect without pain sensation in a patient with a postcentral lesion. Pain, 81, 211–​214. Ploner, M., Sorg, C., & Gross, J. (2017). Brain rhythms of pain. Trends in Cognitive Sciences, 21, 100–​110. Prinstein, M.  J., Heilbron, N., Guerry, J.  D., Franklin, J.  C., Rancourt, D., Simon, V., & Spirito, A. (2010). Peer influence and nonsuicidal self injury: Longitudinal results in community and clinically-​referred adolescent samples. Journal of Abnormal Child Psychology, 38(5), 669–​682. Santangelo, P.  S., Koenig, J., Funke, V., Parzer, P., Resch, F., Ebner-​Priemer, U.  W., … Kaess, M. (2016). Ecological momentary assessment of affective and interpersonal instability in adolescent non-​ suicidal self-​ injury. Journal of Abnormal Child Psychology,  1–​10. Schmahl, C., Bohus, M., Esposito, F.,Treede, R. D., Di Salle, F., Greffrath,W., … Seifritz, E. (2006). Neural correlates of antinociception in borderline personality disorder. Archives of General Psychiatry, 63(6), 659–​666. Schoenleber, M., Berenbaum, H., & Motl, R. (2014). Shame-​related functions of and motivations for self-​ injurious behavior. Personality Disorders:  Theory, Research and Treatment, 5(2), 204–​211. Selby, E. A., Anestis, M. D., & Joiner,T. E. (2008). Understanding the relationship between emotional and behavioral dysregulation:  Emotional cascades. Behavior Research and Therapy, 46(5), 593–​611. Selby, E.  A., Connell, L.  D., & Joiner, T.  E. (2010). The pernicious blend of rumination and fearlessness in non-​suicidal self-​injury. Cognitive Therapy and Research, 34(5), 421–​428. Selby, E. A., Nock, M. K., & Kranzler, A. (2014). How does self-​injury feel? Examining automatic positive reinforcement in adolescent self-​injurers with experience sampling. Psychiatry Research, 215(2), 417–​423. Smith, K.  S., & Berridge, K.  C. (2007). Opioid limbic circuit for reward:  interaction between hedonic hotspots of nucleus accumbens and ventral pallidum. Journal of Neuroscience, 27(7), 1594–​1605. St. Germain, S. A., & Hooley, J. M. (2012). Direct and indirect forms of non-​suicidal self-​ injury: Evidence for a distinction. Psychiatry Research, 197(1), 78–​84. St. Germain, S.  A., & Hooley, J.  M. (2013). Aberrant pain perception in direct and indirect non-​suicidal self-​injury:  An empirical test of Joiner’s interpersonal theory. Comprehensive Psychiatry, 54(6), 694–​701. Taylor, P. J., Jomar, K., Dhingra, K., Forrester, R., Shahmalak, U., & Dickson, J. M. (2018). A meta-​analysis of the prevalence of different functions of non-​suicidal self-​injury. Journal of Affective Disorders, 227, 759–​769. Treede, R. D., Kenshalo, D. R., Gracely, R. H., & Jones, A. K. P. (1999). The cortical representation of pain. Pain, 79, 105–​11. Victor, S. E., & Klonsky, E. D. (2014). Daily emotion in non-​suicidal self-​injury. Journal of Clinical Psychology, 70(4), 364–​375. Weinberg, A., & Klonsky, E.  D. (2012). The effects of self-​injury on acute negative arousal: A laboratory simulation. Motivation and Emotion, 36(2), 242–​254.

58  Jill M. Hooley and Kathryn R. Fox Weismoore, J. T., & Esposito-​Smythers, C. (2010). The role of cognitive distortion in the relationship between abuse, assault, and non-​suicidal self-​injury. Journal of Youth and Adolescence, 39(3), 281–​290. Zubieta, J.  K., Smith, Y.  R., Bueller, J.  A., Xu, Y., Kilbourn, M.  R., Jewett, D.  M., … Stohler, C. S. (2001). Regional mu opioid receptor regulation of sensory and affective dimensions of pain. Science, 293(5528), 311–​315. Zubieta, J.  K., Smith, Y.  R., Bueller, J.  A., Xu, Y., Kilbourn, M.  R., Jewett, D.  M., … Stohler, C. S. (2002). μ-​Opioid receptor-​mediated antinociceptive responses differ in men and women. Journal of Neuroscience, 22(12), 5100–​5107.

Chapter 4

The Neurobiology of Nonsuicidal Self-​I njury Paul L. Plener

Introduction Writing about the neurobiology of Nonsuicidal Self-​Injury (NSSI) in a book, especially a book which also includes the clinical management of NSSI, it is important to first answer the relevance of neurobiology. Given that a neurobiological treatment of NSSI is not available and that psychoactive drugs are not recommended in treatment guidelines for NSSI (Plener et al., 2016), one could easily dismiss this chapter as “l’art pour l’art” and turn to seemingly more clinically relevant chapters. This, however, would be a mistake. Although there are still missing pieces in the puzzle of creating a stringent neurobiological theory of NSSI, research and knowledge are progressing rapidly, increasingly enabling us to get a better understanding of the underlying mechanisms of NSSI. In clinical care, neurobiological research allows us to discuss these findings with patients and caregivers and seek feedback on how applicable these results are to the patient’s everyday experience of NSSI. For example, understanding the underlying neurobiological mechanisms involved in NSSI allows for a better understanding of urges to self-​injure, the role it plays for emotion regulation, reasons why stopping can be so difficult, and the odd experiences patients have regarding the notion of pain. Neurobiological research also tells a story of hope. From our understanding of the underlying neurobiological mechanisms of NSSI, we can see that the alterations we describe are not “fixed,” but changeable. For example, we have learned in the past decade that while the pain threshold is elevated in people injuring themselves, it returns to normal levels after stopping NSSI.We have also learned that higher activations in the amygdala, as seen in both adult patients with borderline personality disorder and teenagers with NSSI, can be countered with real-​time fMRI neurofeedback. This sort of understanding will lead to both better-​informed clinicians as well as better-​informed patients and parents. As the field of research on the neurobiology of NSSI is expanding, there are still some “islands” of knowledge that stand out. As these islands have evolved around clinically relevant themes, it is challenging to develop a systematic approach to summarize the neurobiology of NSSI. It seems feasible to describe these islands first and then work to build bridges between these islands of knowledge

60  Paul L. Plener

later, in an attempt to shape a more comprehensive neurobiological model of NSSI. These islands of knowledge will be discussed in the following sections of this chapter, with a focus on emotion regulation and pain as well as stress response and social stressors. Instead of a more “classical” approach to neurobiological reviews on systems (e.g., hormones, neurotransmitters, brain circuits), this chapter will try to integrate these systems under the mentioned domains. One final disclaimer before closing these introductory remarks:  a lot of research on the neurobiology of NSSI is based on studies of adults with borderline personality disorder (BPD). This does not infer that NSSI is synonymous with BPD, as we know that  –​especially in adolescents  –​most of the young people hurting themselves do not fulfill the criteria for BPD. However, omitting the literature on patients with BPD would drastically limit the amount of knowledge available. Instead, it is important to consider that some of the data presented may have less applicability specifically for NSSI given that factors related more directly to BPD could influence the outcome (e.g., dissociation, with a possible impact on many of the presented domains).

Emotion Regulation and Pain It has often been stated both in the scientific literature and in clinical interaction with patients that NSSI serves a role in stress and emotion regulation (Andover & Morris, 2014; Schmahl et  al., 2014). This proposition is consistent with a recent meta-​analysis showing that intrapersonal functions are primarily reported as motivations for NSSI (Taylor et  al., 2018). In addition, recent findings of ecological momentary assessment studies show that in everyday life, adolescents with NSSI report more affective instability (Santangelo et  al., 2017). Patients often clinically report that they are able to end or diminish a highly arousing negative affective state by injuring themselves. When processing negative emotional stimuli, patients with BPD show a higher activation in the amygdala and the posterior cingulate cortex, while there is a blunted response in the dorsolateral prefrontal cortex (Schulze, Schmahl, & Niedtfeld, 2016). A comparable finding was also reported from adolescents with NSSI, showing an elevated activity pattern of both the amygdala and the anterior cingulate cortex (ACC) when viewing standardized affective pictures (Plener, Bubalo, Fladung, Ludolph, & Lule, 2012). Interestingly, this pattern of elevation was found for not only negative stimuli, but also for positive and neutral stimuli. These findings validate the clinical reality of patients with NSSI, who often describe experiencing significant stress in response to states of high emotional arousal. Interestingly, it has been shown that the application of pain in adult patients with BPD decreases amygdala activation (Schmahl et al., 2006). This effect was also replicated in BPD patients receiving an incision in the forearm while lying in the magnetic resonance imaging (MRI) scanner (Reitz et al., 2015). When talking to people with NSSI, they also indicate a decrease in arousal as they

Neurobiology of NSSI  61

self-​injure. These findings are intriguing given that one of the strongest alarm signals in the body –​pain –​is seemingly overcome with the application of pain or injury. These findings, however, are consistent with a large body of research that has demonstrated an elevated pain threshold in people with repetitive NSSI (Kirtley, O’Carroll, & O’Connor, 2016). According to Nock and Prinstein (2005), individuals who engage in repetitive NSSI indicate an absence of physical pain when engaging in NSSI. Among patients with BPD and NSSI, 70–​80% reported hypalgesia (i.e., decreased sensitivity to painful stimuli) or analgesia (i.e., insensibility to painful stimuli; Schmahl et al., 2004). Schmahl et al. (2004, 2006) found that patients diagnosed with BPD reported lower pain ratings and higher pain thresholds compared to healthy controls when confronted with heat pain stimulation. Ludascher et al. (2009) compared 24 patients with BPD who currently engaged in NSSI (n = 13) and patients who used to engage in NSSI (n = 11) with healthy controls (n = 24). Patients who currently performed NSSI showed the highest pain threshold, followed by the former NSSI group, which was then followed by the healthy control group. Because the pain threshold apparently decreased after stopping NSSI, these findings suggest that hypalgesia is habitual and reversible. Interestingly, there is accumulating evidence that the alterations in the pain threshold are not due to an altered processing of somatosensory aspects of nociceptive stimuli; these systems seem to be intact (Bekrater-​Bodmann et al., 2015). Instead, the hypalgesia appears to be due to an altered affective perception of pain (Bonenberger, Plener, Groschwitz, Gron, & Abler, 2015). As opioids are involved in pain perception, there has been an interest in exploring alterations in opioid levels. Altered opioid levels can be found in patients with a history of repeated NSSI (Coid, Allolio, & Rees, 1983; Sher & Stanley, 2008, 2009). According to the homeostasis model of NSSI (Stanley et  al., 2010), aversive experiences like childhood neglect and genetic vulnerability can lead to a chronically lower level of endogenous opioids which, when experiencing a stressful event, can be restored by engaging in NSSI. In a study of 29 patients who had made suicide attempts and were diagnosed with a Cluster B personality disorder (n = 14 with NSSI, n = 15 without NSSI), Stanley et al. (2010) found that cerebrospinal fluid β-​endorphin and met-​enkephalin levels of endogenous opioids were significantly lower in patients with a history of NSSI. However, it is not clear if these findings apply specifically to NSSI outside of a BPD context (Kirtley, O’Carroll, & O’Connor, 2015). The literature on an altered pain response in NSSI is rich, especially when examining adult patients with NSSI (Koenig, Thayer, & Kaess, 2016; Schmahl & Baumgartner, 2015). A thorough meta-​analysis has provided substantial evidence that higher pain thresholds as well as higher pain tolerance can be found in individuals with NSSI (Koenig, Thayer, & Kaess, 2016). Within the last few years, however, an increasing number of studies has emerged which also focused on adolescent populations. Interestingly, the results with adolescents are sometimes mixed, with some studies reporting an increased pain threshold, while other

62  Paul L. Plener

studies reporting no differences in pain thresholds (Groschwitz, Plener, Groen, Bonenberger, & Abler, 2016; Koenig et al., 2017; Ludascher et al., 2015; Osuch, Ford, Wrath, Bartha, & Neufeld, 2014). There appear to be several positive effects that have been described with regards to administration of painful stimuli. In adolescents with NSSI, mood and body awareness increased following a cold pressor test, while tension did not increase during the task, findings that were in contrast to the healthy controls in this study. Cortisol secretion as well as autonomic arousal were markedly increased in individuals with NSSI, thus allowing for the anti-​dissociative function of NSSI (Koenig et al., 2017). The finding of elevated mood after the cessation of the pain could also be understood in light of the pain-​offset relief mechanism, which is known to enhance mood (Franklin, Lee, Hanna, & Prinstein, 2013), thus representing another reinforcing property of using physical harm to alter emotion. This hypothesis is further supported by an fMRI study in adolescents with NSSI reporting increased activation in the thalamus, the dorsal striatum, and the anterior precuneus during pain offset in comparison to non-​self-​injuring clinical controls (Osuch et al., 2014). Several studies using functional magnetic resonance imaging (fMRI) further explored the role of painful stimuli in regulating emotion. Niedtfeld et al. (2010) confronted 20 adults with BPD and 23 healthy controls with a combination of warm and painful stimuli as well as neutral and negative pictures from the International Affective Picture System. Results from the fMRI showed a significantly higher activation in the amygdala, the ACC, and the insula in patients with BPD during the presentation of both neutral and negative pictures. Also, in a study of adolescent patients with NSSI, Plener et  al. (2012) found increased activation in the amygdala and the ACC for all emotional pictures being viewed. When heat-​induced pain was applied in 12 patients with BPD and NSSI in comparison to 12 healthy controls, increased activity in the dorsolateral prefrontal cortex and decreased activity in the posterior parietal cortex, the perigenual anterior cingulate cortex, and the right amygdala were found in BPD patients compared to healthy controls (Schmahl et al., 2006). Supporting these findings, atypical amygdala–​frontal connectivity (Westlund Schreiner et al., 2017), as well as reduced functional connectivity between right orbitofrontal cortex and anterior cingulate cortex (Osuch et  al., 2014) was also shown in adolescents with NSSI. In a recent study, successful dialectical behavior therapy (DBT) led to a reduction in these alterations in emotion processing, specifically amygdala deactivation after painful stimuli (Niedtfeld et al., 2017). These findings suggest that within the regions responsible for emotional processing, an existing hyperactivation in emotionally dysregulated individuals with NSSI can be countered by the injury, therefore supporting the hypothesis that NSSI serves an active role in emotion regulation by influencing areas in the brain involved with emotion processing. The notion that NSSI “works” to alleviate strong negative emotions is therefore supported by replicated evidence from fMRI studies.

Neurobiology of NSSI  63

Stress Response Because NSSI is often used to cope with aversive emotional states, neurobiological markers of stress regulation have also been investigated in connection with NSSI. Studies often focus on peripheral markers of an altered stress response, such as skin conductance or measure of cardiac responses. Nock and Mendes (2008) compared 62 adolescents with a history of NSSI to 30 matched controls without NSSI. Physiological hyperarousal, as measured by skin conductance, was found among the adolescents with NSSI when confronted with a distressing task. Imagining an act of NSSI decreases physiological tension in individuals with NSSI, as measured by skin conductance and heart rate (Brain, Haines, & Williams, 1998; Haines, Williams, Brain, & Wilson, 1995). Kaess et al. (2012) did not find differences in the heart rate of adolescents with NSSI (n  =  14) and healthy controls (n = 14) in a standardized psychosocial stress protocol. Further, cardiac function, such as vagally mediated heart rate variability, was not altered in a study comparing 30 adolescents with NSSI to 30 healthy controls, although it was related to BPD symptoms (Koenig et al., 2017). The hypothalamic–​pituitary–​adrenal (HPA) axis represents our central stress system, which allows us to react in an appropriate manner (e.g., to fight or flight) to stressors from the outside world.Within this process, cortisol is released from the adrenal glands following a cascade of neurotransmitters and leading to its own downregulation via a negative feedback loop. Cortisol interacts with endogenous opioids and serotonergic mechanisms. Experiencing stress is associated with an elevated secretion of cortisol (Heim, Ehlert, & Hellhammer, 2000). According to Heim et  al. (2000), post​traumatic stress disorder, chronic stress, and stress-​related bodily disorders are correlated with a low baseline cortisol secretion, a finding also described in young adults with NSSI (Plener et al., 2017). Consistent results from studies on cortisol in individuals with NSSI show a reduced cortisol secretion in stressful situations. Findings of an altered cortisol response have also been reported from animal studies. Monkeys with self-​injurious behaviors that were subsequently exposed to stress showed a hyporesponsive HPA axis when experiencing acute stress (Tiefenbacher, Novak, Lutz, & Meyer, 2005). According to Tiefenbacher et al. (2005), it is still unclear whether a hyporesponsive HPA axis leads to self-​injurious behavior, or whether self-​injurious behavior influences the responsiveness of the HPA axis. Another study on rhesus monkeys also reported lower serum cortisol in monkeys biting themselves when compared to monkeys not hurting themselves after stress due to relocation. This difference, however, was not significant (Davenport, Lutz, Tiefenbacher, Novak, & Meyer, 2008). A study of bushbabies showed significantly lower levels of plasma cortisol in animals with self-​injurious behaviors (Watson, McCoy, Fontenot, Hanbury, & Ward, 2009). More recently, several studies have focused on the cortisol response in adolescents with NSSI. In adolescents with NSSI, cortisol concentrations were raised in the morning (Reichl et al., 2016) and lowered in the dexamethasone

64  Paul L. Plener

suppression test (Beauchaine, Crowell, & Hsiao, 2015). Interestingly, adolescents with NSSI show a stronger cortisol response to pain stimuli (Koenig et al., 2017). Kaess et  al. (2012) reported that adolescents who engaged in NSSI (n  =  14) showed a hyporesponsive HPA axis in a social stress task, compared to healthy controls (n = 14). This finding is consistent with a more recent study using a different cortisol collection methodology (i.e., levels of cortisol in the blood vs. saliva levels of cortisol) but the same standardized stressor, the Trier social stress task, in a larger sample (n = 130), showing significantly lower blood levels of cortisol which could not be explained by early psychosocial adversity (Plener et al., 2017). These findings support the proposition that individuals with NSSI seem to be prone to an elevated stress reactivity. Especially when encountering social stressors, there are replicated findings showing an altered response of the HPA axis centrally involved in the stress response. This supports the notion that individuals with NSSI experience stress more frequently, especially in social situations.

Social Stress Although interpersonal functions of NSSI are reported less common as motivations by individuals with NSSI than intrapersonal functions (Taylor et  al., 2018), there is a strong association between NSSI and bullying (Brunstein Klomek et  al., 2016; Lereya, Copeland, Costello, & Wolke, 2015), which can also be understood as a severe interpersonal stressor. Adolescents with NSSI seem to process social stressors differently. Following up on the aforementioned alterations in the HPA axis under social stressor tasks (Kaess et al., 2012; Plener et  al., 2017), it seems reasonable to assume that individuals with NSSI might react differently when faced with social stressors. It is currently unknown, however, whether these altered reactions are based on genetic alterations or whether they evolve over time as part of difficult social interactions in real life. A genetic study showed that in carriers of at least one short allele in the serotonin transporter-​linked polymorphic region (5-​HTTLPR) of the SLC6A4 gene, NSSI is more common when adolescents encounter severe interpersonal stress (Hankin, Barrocas,Young, Haberstick, & Smolen, 2015).This is the first example of a gene–​environment interaction. Because of the singularity of the finding, further studies of gene–​environment interactions are needed. Similarly, it was shown that social exclusion in depressed adolescents with NSSI, compared with adolescents without NSSI and health controls, resulted in differences in activation in different cerebral regions, such as the medial prefrontal cortex, parahippocampus, and supplementary motor area (Groschwitz, Plener, Groen, Bonenberger, & Abler, 2016). It has been shown that in patients with BPD, altered functional brain activations exist both during social inclusion as well as during social exclusion (Domsalla et  al., 2014) and are interlinked with pain processing (Bungert et al., 2015). In contrast, patients with NSSI show

Neurobiology of NSSI  65

alterations which are limited to situations involving social exclusion (Brown et al., 2017). This finding might be understood as a generalization that occurs over time as BPD develops (Brown et  al., 2017). Regardless, from a clinical perspective, it seems reasonable to assume that adolescents with NSSI are particularly sensitive to social exclusion from groups. The findings shown here highlight the extent of interactions between neurobiological deviations and risk factors, such as bullying, in NSSI.

Conclusion This chapter had the aim of both summarizing the state of knowledge about neurobiological mechanisms of NSSI as well as building bridges, not only between different findings, but also between the findings and the clinical reality of treating patients with NSSI. Although our understanding of the neurobiological processes involved in NSSI is far from ideal, scientific knowledge about these neurobiological mechanisms has progressed rapidly in the last 10–​15 years, going from a state in which there were hardly any studies to a differentiated scientific debate in some areas, such as the interplay between pain stimulation and emotion regulation. The development of this research was supported by the theoretical frameworks that underscore the diagnosis of NSSI in section three of the DSM-​5. Given the fact that NSSI is registered as a “condition for further study” in the DSM-​5, it seems likely that neurobiological research can aid to inform the debate about whether NSSI should be included as an independent disorder. To date, evidence clearly supporting this point of view is ambivalent: although some studies show differences in individuals with NSSI compared to healthy controls and clinical controls without NSSI (e.g., Groschwitz et al., 2016; Osuch et al., 2014), comorbidity seems to be the rule, rather than the exception, in NSSI. Given this, it certainly makes sense to develop a transdiagnostic approach in research to decipher the mechanisms behind NSSI. Especially from a neurobiological perspective, developing an understanding that is based on the (dys)functions of various systems is crucial to understanding NSSI and can support our clinical approaches. The NIMH proposed research domain criteria is likely to be a more useful approach than diagnoses to further our understanding in this field (Westlund Schreiner, Klimes-​Dougan, Begnel, & Cullen, 2015). In summary, there is neurobiological evidence to suggest that individuals with NSSI seem to show an altered stress response, which seems especially pronounced in response to interpersonal stressors. Due to the lack of longitudinal designs, however, it remains unclear whether these alterations present a vulnerability which exists before initiation of NSSI, or whether these alterations are encountered as a response to NSSI. Similarly, it is unclear if the increase in pain threshold is genetically determined and present before NSSI initiation, or if it is acquired through NSSI. The latter seems likely, given that the aforementioned studies with adolescents sometimes failed to find evidence for an elevated

66  Paul L. Plener

threshold, and the threshold decreased after the cessation of NSSI.To date, however, there is insufficient evidence from longitudinal research to support either hypothesis. There are very few studies which examined individuals who have not started NSSI. One such study shows an elevated sensitivity to anticipated rewards in adolescents with thoughts about NSSI while in the fMRI (Poon, Thompson, Forbes, & Chaplin, 2018). Given the existing findings, it seems most likely that NSSI is used to counter stress, which suggests a certain vulnerability to stress in individuals with NSSI. Vulnerabilities for this altered stress response might include early life stress (e.g., child abuse, maltreatment, and neglect) and difficulties with parental relationships, both of which have been shown to be associated with NSSI. These early adverse experiences could alter the stress response, leading to a heightened vulnerability to certain stressors in later development, possibly explaining the association between bullying and NSSI, especially considering the neurobiological findings about social stressors. NSSI regulates this altered emotion processing system in the brain, thus making NSSI a coping strategy that is consistently reinforced and difficult to stop. Following this line of thought, and consistent with existing effective interventions, clinical treatment needs to focus on identifying stressors and building alternative strategies to cope with stress, both intrapersonal as well as interpersonal stress. To progress from where we are in the understanding of the neurobiology of NSSI, there is a need for a deeper understanding through more sophisticated studies. First, it will be necessary to understand the interplay between different mechanisms by connecting research methodologies and simultaneously examining alterations in different neurobiological systems. We will also need to progress towards a clearer neurobiological understanding of the mechanisms involved in improvement  –​or worsening  –​of NSSI over time. Longitudinal approaches are required which, given the peak of NSSI in adolescence, must be contextualized within a developmental psychopathology perspective. Better understanding of which neurobiological changes underlie recovery in NSSI also has the potential to inform therapy. Last, but certainly not least, neurobiological research has the potential to enter the realms of therapy itself. As evidenced by recent research projects, technologies such as fMRI, with the potential to receive input from subcortical areas, can be used therapeutically to alter the circuits involved in emotion processing (Nicholson et al., 2017; Paret et al., 2016). Using the knowledge gained from neurobiological mechanisms to enhance therapeutic interventions should be the next goal in linking basic research and clinical work.

References Andover, M. S., & Morris, B. W. (2014). Expanding and clarifying the role of emotion regulation in nonsuicidal self-​ injury. Canadian Journal of Psychiatry, 59, 569–​ 575. doi:10.1177/​070674371405901102

Neurobiology of NSSI  67 Beauchaine, T.  P., Crowell, S.  E., & Hsiao, R.  C. (2015). Post-​dexamethasone cortisol, self-​inflicted injury, and suicidal ideation among depressed adolescent girls. Journal of Abnormal Child Psychology, 43, 619–​632. doi:10.1007/​s10802-​014-​9933-​2 Bekrater-​ Bodmann, R., Chung, B.  Y., Richter, I., Wicking, M., Foell, J., Mancke, F., … Flor, H. (2015). Deficits in pain perception in borderline personality disorder:  Results from the thermal grill illusion. Pain, 156, 2084–​2092. doi:10.1097/​ j.pain.0000000000000275 Bonenberger, M., Plener, P.  L., Groschwitz, R.  C., Gron, G., & Abler, B. (2015). Differential neural processing of unpleasant haptic sensations in somatic and affective partitions of the insula in non-​suicidal self-​injury (NSSI). Psychiatry Research, 234, 298–​304. doi:10.1016/​j.pscychresns.2015.10.013 Brain, K.  L., Haines, J., & Williams, C.  L. (1998). The psychophysiology of self-​ mutilation: Evidence of tension reduction. Archives of Suicide Research, 4, 227–​242. Brown, R. C., Plener, P. L., Groen, G., Neff, D., Bonenberger, M., & Abler, B. (2017). Differential neural processing of social exclusion and inclusion in adolescents with non-​suicidal self-​injury and young adults with borderline personality disorder. Frontiers of Psychiatry, 8, 267. doi:10.3389/​fpsyt.2017.00267 Brunstein Klomek, A., Snir, A., Apter, A., Carli, V., Wasserman, C., Hadlaczky, G., … Wasserman, D. (2016). Association between victimization by bullying and direct self injurious behavior among adolescence in Europe: A ten-​country study. European Child and Adolescent Psychiatry, 25, 1183–​1193. doi:10.1007/​s00787-​016-​0840-​7 Bungert, M., Koppe, G., Niedtfeld, I., Vollstadt-​Klein, S., Schmahl, C., Lis, S., & Bohus, M. (2015). Pain processing after social exclusion and its relation to rejection sensitivity in borderline personality disorder. PLoS ONE, 10, e0133693. doi:10.1371/​journal. pone.0133693 Coid, J., Allolio, B., & Rees, L. H. (1983). Raised plasma metenkephalin in patients who habitually mutilate themselves. Lancet, 2, 545–​546. Davenport, M. D., Lutz, C. K., Tiefenbacher, S., Novak, M. A., & Meyer, J. S. (2008). A rhesus monkey model of self-​ injury:  Effects of relocation stress on behavior and neuroendocrine function. Biological Psychiatry, 63, 990–​ 996. doi:10.1016/​ j.biopsych.2007.10.025 Domsalla, M., Koppe, G., Niedtfeld, I.,Vollstadt-​Klein, S., Schmahl, C., Bohus, M., & Lis, S. (2014). Cerebral processing of social rejection in patients with borderline personality disorder. Social Cognitive and Affective Neuroscience, 9, 1789–​1797. doi:10.1093/​ scan/​nst176 Franklin, J. C., Lee, K. M., Hanna, E. K., & Prinstein, M. J. (2013). Feeling worse to feel better: Pain-​offset relief simultaneously stimulates positive affect and reduces negative affect. Psychological Science, 24, 521–​529. doi:10.1177/​0956797612458805 Groschwitz, R.  C., Plener, P.  L., Groen, G., Bonenberger, M., & Abler, B. (2016). Differential neural processing of social exclusion in adolescents with non-​suicidal self-​ injury:  An fMRI study. Psychiatry Research:  Neuroimaging, 255, 43–​49. doi:10.1016/​ j.pscychresns.2016.08.001 Haines, J., Williams, C. L., Brain, K. L., & Wilson, G. V. (1995). The psychophysiology of self-​mutilation. Journal of Abnormal Psychology, 104, 471–​489. Hankin, B.  L., Barrocas, A.  L., Young, J.  F., Haberstick, B., & Smolen, A. (2015). 5-​ HTTLPR × interpersonal stress interaction and nonsuicidal self-​ injury in general community sample of youth. Psychiatry Research, 225, 609–​612. doi:10.1016/​ j.psychres.2014.11.037

68  Paul L. Plener Heim, C., Ehlert, U., & Hellhammer, D. H. (2000). The potential role of hypocortisolism in the pathophysiology of stress-​ related bodily disorders. Psychoneuroendocrinology, 25,  1–​35. Kaess, M., Hille, M., Parzer, P., Maser-​ Gluth, C., Resch, F., & Brunner, R. (2012). Alterations in the neuroendocrinological stress response to acute psychosocial stress in adolescents engaging in nonsuicidal self-​injury. Psychoneuroendocrinology, 37, 157–​161. doi:10.1016/​j.psyneuen.2011.05.009 Kirtley, O. J., O’Carroll, R. E., & O’Connor, R. C. (2015).The role of endogenous opioids in non-​suicidal self-​injurious behavior:  Methodological challenges. Neuroscience and Biobehavioral Reviews, 48, 186–​189. doi:10.1016/​j.neubiorev.2014.11.007 Kirtley, O.  J., O’Carroll, R.  E., & O’Connor, R.  C. (2016). Pain and self-​harm:  A systematic review. Journal of Affective Disorders, 203, 347–​ 363. doi:10.1016/​ j.jad.2016.05.068 Koenig, J., Rinnewitz, L., Parzer, P., Resch, F., Thayer, J. F., & Kaess, M. (2017). Resting cardiac function in adolescent non-​suicidal self-​injury: The impact of borderline personality disorder symptoms and psychosocial functioning. Psychiatry Research, 248, 117–​120. doi:10.1016/​j.psychres.2016.12.024 Koenig, J., Thayer, J. F., & Kaess, M. (2016). A meta-​analysis on pain sensitivity in self-​ injury. Psychological Medicine, 46, 1597–​1612. doi:10.1017/​S0033291716000301 Lereya, S. T., Copeland, W. E., Costello, E. J., & Wolke, D. (2015). Adult mental health consequences of peer bullying and maltreatment in childhood: Two cohorts in two countries. Lancet Psychiatry, 2, 524–​531. doi:10.1016/​S2215-​0366(15)00165-​0 Ludascher, P., Greffrath, W., Schmahl, C., Kleindienst, N., Kraus, A., Baumgartner, U., … Bohus, M. (2009). A cross-​sectional investigation of discontinuation of self-​injury and normalizing pain perception in patients with borderline personality disorder. Acta Psychiatrica Scandinavica, 120, 62–​70. doi:10.1111/​j.1600-​0447.2008.01335.x Ludascher, P., von Kalckreuth, C., Parzer, P., Kaess, M., Resch, F., Bohus, M., … Brunner, R. (2015). Pain perception in female adolescents with borderline personality disorder. European Child and Adolescent Psychiatry, 24, 351–​357. doi:10.1007/​ s00787-​014-​0585-​0 Nicholson, A. A., Rabellino, D., Densmore, M., Frewen, P. A., Paret, C., Kluetsch, R., … Lanius, R. A. (2017). The neurobiology of emotion regulation in posttraumatic stress disorder: Amygdala downregulation via real-​time fMRI neurofeedback. Human Brain Mapping, 38, 541–​560. doi:10.1002/​hbm.23402 Niedtfeld, I., Schmitt, R., Winter, D., Bohus, M., Schmahl, C., Sabine, C., & Herpertz, S.  C. (2017). Pain-​mediated affect regulation is reduced after dialectical behavior therapy in borderline personality disorder: A longitudinal fMRI study. Social Cognitive and Affective Neuroscience, 12, 739–​747. doi:10.1093/​scan/​nsw183. Niedtfeld, I., Schulze, L., Kirsch, P., Herpertz, S. C., Bohus, M., & Schmahl, C. (2010). Affect regulation and pain in borderline personality disorder:  A possible link to the understanding of self-​ injury. Biological Psychiatry, 68, 383–​ 391. doi:10.1016/​ j.biopsych.2010.04.015 Nock, M. K., & Mendes, W. B. (2008). Physiological arousal, distress tolerance, and social problem-​ solving deficits among adolescent self-​ injurers. Journal of Consulting and Clinical Psychology, 76, 28–​38. doi:10.1037/​0022-​006X.76.1.28 Nock, M.  K., & Prinstein, M.  J. (2005). Contextual features and behavioral functions of self-​mutilation among adolescents. Journal of Abnormal Psychology, 114, 140–​146. doi:10.1037/​0021-​843X.114.1.140

Neurobiology of NSSI  69 Osuch, E., Ford, K.,Wrath, A., Bartha, R., & Neufeld, R. (2014). Functional MRI of pain application in youth who engaged in repetitive non-​suicidal self-​injury vs. psychiatric controls. Psychiatry Research, 223, 104–​112. doi:10.1016/​j.pscychresns.2014.05.003 Paret, C., Kluetsch, R., Zaehringer, J., Ruf, M., Demirakca, T., Bohus, M., … Schmahl, C. (2016). Alterations of amygdala–​ prefrontal connectivity with real-​ time fMRI neurofeedback in BPD patients. Social Cognitive and Affective Neuroscience, 11, 952–​960. doi:10.1093/​scan/​nsw016 Plener, P. L., Brunner, R., Fegert, J. M., Groschwitz, R. C., In-​Albon, T., Kaess, M., … Becker, K. (2016). Treating nonsuicidal self-​injury (NSSI) in adolescents: Consensus based German guidelines. Child and Adolescent Psychiatry and Mental Health, 10, 46. doi: 10.1186/​s13034-​016-​0134-​3 Plener, P.  L., Bubalo, N., Fladung, A.  K., Ludolph, A.  G., & Lule, D. (2012). Prone to excitement: Adolescent females with non-​suicidal self-​injury (NSSI) show altered cortical pattern to emotional and NSS-​related material. Psychiatry Research: Neuroimaging, 203, 146–​152. doi:10.1016/​j.pscychresns.2011.12.012 Plener, P. L., Zohsel, K., Hohm, E., Buchmann, A. F., Banaschewski, T., Zimmermann, U. S., & Laucht, M. (2017). Lower cortisol level in response to a psychosocial stressor in young females with self-​harm. Psychoneuroendocrinology, 76, 84–​87. doi:10.1016/​ j.psyneuen.2016.11.009 Poon, J. A.,Thompson, J. C., Forbes, E. E., & Chaplin,T. M. (2018). Adolescents’ reward-​ related neural activation: links to thoughts of nonsuicidal self-​injury. Suicide and Life Threatening Behavior. doi:10.1111/​sltb.12418 Reichl, C., Heyer, A., Brunner, R., Parzer, P.,Volker, J. M., Resch, F., & Kaess, M. (2016). Hypothalamic–​pituitary–​adrenal axis, childhood adversity and adolescent nonsuicidal self-​injury. Psychoneuroendocrinology, 74, 203–​211. doi:10.1016/​j.psyneuen.2016.09.011 Reitz, S., Kluetsch, R., Niedtfeld, I., Knorz, T., Lis, S., Paret, C., … Schmahl, C. (2015). Incision and stress regulation in borderline personality disorder:  Neurobiological mechanisms of self-​ injurious behavior. British Journal of Psychiatry, 207, 165–​ 172. doi:10.1192/​bjp.bp.114.153379 Santangelo, P. S., Koenig, J., Funke,V., Parzer, P., Resch, F., Ebner-​Priemer, U. W., & Kaess, M. (2017). Ecological momentary assessment of affective and interpersonal instability in adolescent non-​suicidal self-​injury. Journal of Abnormal Child Psychology, 45, 1429–​ 1438. doi:10.1007/​s10802-​016-​0249-​2 Schmahl, C., & Baumgartner, U. (2015). Pain in borderline personality disorder. Modern Trends in Pharmacopsychiatry, 30, 166–​175. doi:10.1159/​000435940 Schmahl, C., Bohus, M., Esposito, F.,Treede, R. D., Di Salle, F., Greffrath,W., … Seifritz, E. (2006). Neural correlates of antinociception in borderline personality disorder. Archives of General Psychiatry, 63, 659–​667. doi:10.1001/​archpsyc.63.6.659 Schmahl, C., Greffrath, W., Baumgartner, U., Schlereth, T., Magerl, W., Philipsen, A., … Treede, R.  D. (2004). Differential nociceptive deficits in patients with borderline personality disorder and self-​injurious behavior: Laser-​evoked potentials, spatial discrimination of noxious stimuli, and pain ratings. Pain, 110, 470–​479. doi:10.1016/​ j.pain.2004.04.035 Schmahl, C., Herpertz, S. C., Bertsch, K., Ende, G., Flor, H., Kirsch, P., … Bohus, M. (2014). Mechanisms of disturbed emotion processing and social interaction in borderline personality disorder: State of knowledge and research agenda of the German Clinical Research Unit. Borderline Personality Disorder and Emotion Dysregulation, 1, 12. doi:10.1186/​2051-​6673-​1-​12

70  Paul L. Plener Schulze, L., Schmahl, C., & Niedtfeld, I. (2016). Neural correlates of disturbed emotion processing in borderline personality disorder:  A multimodal meta-​analysis. Biological Psychiatry, 79, 97–​106. doi:10.1016/​j.biopsych.2015.03.027 Sher, L., & Stanley, B.  H. (2008). The role of endogenous opioids in the pathophysiology of self-​injurious and suicidal behavior. Archives of Suicide Research, 12, 299–​308. doi:10.1080/​13811110802324748 Sher, L., & Stanley, B. H. (2009). Biological models of nonsuicidal self injury. In M. K. Nock (Ed.), Understanding nonsuicidal self-​injury (pp. 99–​117). Washington, DC:  American Psychological Association. Stanley, B., Sher, L.,Wilson, S., Ekman, R., Huang,Y. Y., & Mann, J. J. (2010). Non-​suicidal self-​injurious behavior, endogenous opioids and monoamine neurotransmitters. Journal of Affective Disorders, 124, 134–​140. doi:10.1016/​j.jad.2009.10.028 Taylor, P. J., Jomar, K., Dhingra, K., Forrester, R., Shahmalak, U., & Dickson, J. M. (2018). A meta-​analysis of the prevalence of different functions of non-​suicidal self-​injury. Journal of Affective Disorders, 227, 759–​769. doi:10.1016/​j.jad.2017.11.073 Tiefenbacher, S., Novak, M. A., Lutz, C. K., & Meyer, J. S. (2005). The physiology and neurochemistry of self-​injurious behavior: A nonhuman primate model. Frontiers of Bioscience, 10, 1–​11. Watson, S.  L., McCoy, J.  G., Fontenot, M.  B., Hanbury, D.  B., & Ward, C.  P. (2009). L-​ tryptophan and correlates of self-​ injurious behavior in small-​ eared bushbabies (Otolemur garnettii). Journal of the American Association for Laboratory Animal Science, 48, 185–​191. Westlund Schreiner, M., Klimes-​Dougan, B., Begnel, E.  D., & Cullen, K.  R. (2015). Conceptualizing the neurobiology of non-​suicidal self-​injury from the perspective of the Research Domain Criteria Project. Neuroscience and Biobehavioral Reviews, 57, 381–​391. doi:10.1016/​j.neubiorev.2015.09.011 Westlund Schreiner, M., Klimes-​Dougan, B., Mueller, B. A., Eberly, L. E., Reigstad, K. M., Carstedt, P.  A., … Cullen, K.  R. (2017). Multi-​modal neuroimaging of adolescents with non-​suicidal self-​injury:  Amygdala functional connectivity. Journal of Affective Disorders, 221, 47–​55. doi:10.1016/​j.jad.2017.06.004

Chapter 5

Diagnostic Classification of Nonsuicidal Self-​I njury Amy Brausch

Introduction Researchers have advocated for the recognition of a separate clinical disorder for nonsuicidal self-​injury (NSSI) for over a decade (e.g., Briere & Gill, 1998; Muehlenkamp, 2005; Ross & Heath, 2002). In the proposed 11th edition of the International Classification of Diseases, NSSI is included as a behavioral “symptom” or “sign,” but is not identified as a separate disorder with specified criteria (World Health Organization, 2018). Similarly, within the Diagnostic and Statistical Manual of Mental Disorders (DSM), NSSI was recognized only as a symptom of borderline personality disorder (BPD) for many years. The 2013 edition of the DSM, however, challenged this approach, acknowledging NSSI as a disorder for further study (DSM-​5; American Psychiatric Association [APA], 2013).The designation of NSSI as a condition requiring further research was a step forward in recognizing this behavior as clinically significant outside of other diagnoses, a point solidified by evidence that up to 80% of adolescents meeting criteria for NSSI Disorder (NSSID) do not meet criteria for BPD (In-​Albon, Ruf, & Schmid, 2013). That being said, the proposed criteria for NSSID have been evaluated and heavily critiqued since being released. The past several years of research on the criteria have resulted in a range of results –​from dismally performing field trials to newly proposed empirically derived cut-​offs for frequency and duration criteria. This chapter aims to summarize the current critiques of the DSM-​5 proposed criteria for nonsuicidal self-​injury disorder (NSSID), provides an update on empirical work that attempts to hone and improve the criteria, discusses the importance of having a diagnostic label for NSSI, and offers thoughts on potential alternatives to the proposed diagnostic criteria.

NSSI Disorder –​Thoughtfully Proposed, Poorly Evaluated for DSM-​5 Nonsuicidal self-​injury (NSSI) has been recognized as a maladaptive and clinically significant behavior for decades, but it was historically considered to be primarily a symptom of BPD. In fact, patients who engaged in NSSI were often

72  Amy Brausch

diagnosed as having BPD even if they did not meet full criteria, depending on clinicians’ biases and degree of familiarity with NSSI (Ghaziuddin, Tsai, Naylor, & Ghaziuddin, 1992; Suyemoto, 1998). Researchers and clinicians began voicing their concerns that BPD was not an appropriate diagnosis for all patients who engaged in NSSI, and that NSSI behavior was distinct from self-​harm behavior with lethal intent. As early as the 1960s, researchers published reviews of studies describing a syndrome of self-​cutting (Graff & Mallin, 1967; Pao, 1969), but it was not widely accepted due to their inclusion of suicide attempts in the definition. In 1993, Favazza and Rosenthal published a paper regarding “diagnostic issues in self-​mutilation” and noted that “repetitive superficial or moderate self-​ mutilation” is often associated with multiple psychiatric diagnoses and should be considered as its own syndrome (Favazza & Rosenthal, 1993). These researchers conceptualized NSSI as an “impulse disorder” (p.  134). Research on NSSI exploded in the 2000s and has been going strong ever since. Recommendations for a separate clinical diagnosis also continued, notably by a compelling review paper by Muehlenkamp (2005). Not long after, a proposal was submitted to the DSM-​5 Childhood Disorder and Mood Disorder Work Groups to include NSSI as a new disorder (Shaffer & Jacobson, 2009). This proposal laid out initial criteria for NSSID based on the empirical evidence up to that point. It is interesting to note that the disorder was proposed for these two workgroups rather than the workgroup focusing on Impulse Disorders, as Favazza had suggested years before. Regardless, NSSID was then evaluated in the DSM-​5 field trials. Many studies have since cited the results of the field trials showing that NSSID criteria performed poorly among clinicians rating it. However, closer inspection of the field trials highlights significant limitations for how NSSID was evaluated (Regier et al., 2013). First, NSSID was only evaluated by child and adolescent sites, limiting evaluation of the criteria to individuals who were likely just beginning to engage in NSSI and eliminating the ability to evaluate the criteria in adults with a longer duration of NSSI. Second, only four child and adolescent sites were chosen for the field trials, and only three of these evaluated NSSID. Two sites were unable to obtain large enough sample sizes to calculate kappa estimates and were deemed “unsuccessful” due to their inability to guarantee precision in estimating the reliability coefficient. The remaining site was deemed to have a successful field trial, but only evaluated seven children and the kappa was found to be in the unacceptable range. The authors of the report describing the field trial noted that the inability to obtain adequate sample sizes for more than one diagnosis under evaluation was a major limitation that was not anticipated. They recommended further pilot studies to evaluate NSSID, among other newly proposed disorders. Thus, NSSID was not included as a new disorder in DSM-​5 but was relegated to Section III as a “condition needing further study.” Researchers have since noted the minimal effort put forth in the field trials to evaluate NSSID, but have also taken the opportunity to further evaluate the proposed criteria for greater precision in diagnosis and clinical utility.

Diagnostic Classification of NSSI  73

Critiques/​C oncerns with DSM-​5 Criteria NSSID remains a condition in need of more extensive research due to inconsistencies and poor reliability among field trials when testing the existing diagnostic criteria (Regier et al., 2013; Washburn, Potthoff, Juzwin, & Styer, 2015). There is currently disagreement about how well the proposed criteria for NSSID adequately reflect clinically significant NSSI behavior. One survey of clinicians and NSSI researchers indicated that most felt the proposed criteria reflected an accurate prototype of a patient with NSSI (Lengel & Mullins-​Sweatt, 2013). Multiple studies have been published using NSSID criteria to evaluate prevalence and features of NSSI in various samples (e.g., Andover, 2014; Plener et al., 2016; Selby, Bender, Gordon, Nock, & Joiner, 2012; Washburn, Potthoff, Juzwin, & Styer, 2015; Zetterqvist, Lundh, Dahlstrom, & Svedin, 2013), while others have focused on evaluating specific criteria for usefulness and accuracy (e.g., Ammerman, Jacobucci, Kleiman, Muehlenkamp, & McCloskey, 2017; Brausch, Muehlenkamp, & Washburn, 2016; Muehlenkamp, Brausch, & Washburn, 2017; Zetterqvist, 2017). The following section summarizes the current critiques of the proposed NSSID criteria. As currently written, the diagnostic criteria included in the DSM-​5 (APA, 2013) specify that an individual must engage in acts of intentional self-​injury that cause damage to the surface of the body on five or more days within the past year. The injuries must be likely to cause bleeding, bruising, or other pain, and are engaged in with no suicidal intent (Criterion A). Additionally, Criterion B specifies that the behavior must be performed for at least one of the following reasons: (1) to relieve negative thoughts or feelings, (2) to resolve an interpersonal problem, or (3)  to cause a positive feeling or emotion. NSSI must also be associated with negative thoughts or feelings and/​or interpersonal problems immediately prior to engaging in the behavior, preoccupation with the behavior that is difficult to resist, or the frequent urge to engage in the behavior (Criterion C). The NSSI behavior cannot include acts that are socially sanctioned or be exclusively scab-​picking or nail-​biting (Criterion D), must cause clinically significant distress or functional impairment (Criterion E), and must not occur exclusively in the context of another mental disorder (Criterion F). A handful of recent studies have investigated the applicability of the proposed criteria for NSSI as outlined in the DSM-​5 (APA, 2013) within a variety of samples (Andover, 2014; Glenn & Klonsky, 2013; Washburn et al., 2015). Many of these studies have found empirical evidence to support NSSID that is distinct from other diagnoses and is associated with a range of adverse effects, additional psychopathology, functional impairments, and distress. Still, each study has also called into question the relevance, utility, and validity of some of the criterion symptoms.

Criterion A The current threshold of NSSI occurring on five or more days in the past year was largely based on theoretical works suggesting that five or more acts

74  Amy Brausch

of NSSI indicated repetitive self-​injury potentially worthy of clinical intervention (e.g., Favazza & Rosenthal, 1993; Muehlenkamp, 2005; Shaffer & Jacobson, 2009). Experts in the field of NSSI have expressed concern that the current specifications of Criterion A might not accurately capture the recency and frequency requirements in a way that meaningfully differentiates between subclinical and clinical levels of NSSI (Selby, Kranzler, Fehling, & Panza, 2015). Studies have reported that among those meeting current criteria for NSSID, a significant proportion engaged in the behavior well over five times. For example, in a community sample of adults, Andover (2014) found that participants in the NSSID group (11.2% of those with an NSSI history) reported having engaged in NSSI on a mean of 86 days in the past year compared to a mean of six days for the non-​disordered group. Note that the mean number of days for engaging in NSSI within the non-​disordered group is greater than the current Criterion A  specification. Similarly, within a clinical sample seeking treatment for self-​ harm, Washburn and colleagues (2015) found that participants meeting diagnostic criteria for NSSID (83% of sample) reported a much higher frequency of NSSI within the past year (mean days = 76.8) compared to the group with NSSI history but not meeting disorder criteria (mean days  =  1.9). Among a community sample of adolescents in Sweden, 6.7% met criteria for NSSID with a majority of those individuals reporting 11 or more acts of NSSI in the past year (Zetterquist et al., 2013). The results from these few studies evaluating NSSID indicate individuals meeting Criterion A, on average, are reporting 2–​17 times more frequent NSSI acts than what is currently specified by the DSM-​5. Additionally, the current Criterion A  specifications appear to result in prevalence rates of NSSID ranging from 3% (community sample; Andover, 2014) to 50% (adolescent psychiatric inpatients; Glenn & Klonsky, 2013), which is relatively high compared to rates of other common disorders found in the general population. In addition to these studies, a few others have taken an empirically derived approach to establishing clinically useful frequency and duration criteria for NSSID. For example, using discriminant function analysis, Muehlenkamp and Brausch (2016) identified significant differentiation between undergraduate students with ten or more NSSI acts and those with 1–​9, and between those who had NSSI in the past 12  months compared to those with NSSI more than 12  months ago. Once individuals were grouped into these “new” criteria, comparisons revealed the 10+ frequency group to report more functions for NSSI, greater psychopathology, more distress, and more impairment than the 1–​9 frequency group. By comparison, Ammerman and colleagues (2017) found that undergraduate students with six or more NSSI acts represented a more severe group of self-​injurers than those with 1–​5 acts using exploratory data-​mining techniques. In a large sample of adolescent inpatients with NSSI, discriminant function analysis identified a cut-​off of NSSI on 25 or more days, and adolescents in this high NSSI group reported greater NSSI severity, depression, substance abuse, BPD features, and suicide ideation and plans

Diagnostic Classification of NSSI  75

compared to moderate (5–​24 days) and low (1–​4 days) groups (Muehlenkamp et al., 2017). Clearly, the existing research calls into question the validity of Criterion A and whether the current specifiers are too liberal, possibly over-​pathologizing individuals who engage in NSSI intermittently. To be considered a clinical disorder, it seems logical that an individual would engage in the problem behavior more than the current DSM implies, which is less than once every other month over a 12-​month period. Comparatively, to qualify for a diagnosis of bulimia nervosa (a disorder which also has a high prevalence of NSSI behavior; Claes & Muehlenkamp, 2014), an individual must engage, on average, in binge and purge behaviors at least once per week for three months (APA, 2013). It can be argued that the clinical threshold for a behavior that is being considered for inclusion as a psychiatric disorder should warrant more frequent and chronic engagement, which the current Criterion A  specifiers do not appear to represent. Furthermore, clinical specifiers for a diagnostic cut-​off should produce groups that represent a high level of severity and significantly differ across other key features and correlates of the disorder. Again, studies indicate that the current diagnostic criteria fall short of this goal.Thus, the current frequency and recency specification of Criterion A may not be contributing to a meaningful differentiation between a clinical and a subclinical group of self-​injurers.

Criterion B Criterion B specifies that self-​injurious behavior must be performed for at least one of the following reasons: (1) to relieve negative thoughts or feelings, (2) to resolve an interpersonal problem, or (3) to cause a positive feeling or emotion. Studies that were published well before the DSM-​5 (APA, 2013) indicate that almost all individuals who engage in NSSI report at least one function of the behavior, which is most commonly some form of affect regulation (Klonsky, 2007). Initial investigations of the DSM-​5 Criterion B have generally revealed that identifying specific functions has limited clinical utility, with one study finding that 87.7% of a sample of patients with current NSSI reported at least one function of NSSI and almost 25% reported all three of the Criterion B functions (Washburn et al., 2015). Almost all participants (98%) in an adolescent inpatient sample who met Criterion A reported affect regulation as a function of their NSSI, followed by marking distress (89%), self-​punishment (88%), and anti-​ dissociation (88%), again indicating that functions of NSSI may not be adding diagnostic utility to NSSID (Glenn & Klonsky, 2013). Additional evidence for the universality of NSSI functions come from studies that find high rates (85–​ 100%) of function endorsement in a variety of samples (In-​Albon et al., 2013; Turner et al., 2012; Zetterqvist et al., 2013). Other studies have reported comparable results showing that participants who meet Criterion A of NSSID are not meaningfully distinguished from those who do not meet Criterion A when it comes to the functions endorsed (e.g., Barrocas et al., 2012; Glenn & Klonsky,

76  Amy Brausch

2013), or assessments of distress and impairment (Andover, 2014). Very few studies provide descriptive information regarding the mean number of functions endorsed, but one study reported an average of 4.76 functions endorsed in a high school sample (Lloyd-​Richardson, Perrine, Dierker, & Kelley, 2007) and another reported an average of 4.23 in an undergraduate sample and 5.16 in an adolescent/​adult inpatient sample (Brausch et al., 2016). Thus, it appears that the number and types of functions specified in Criterion B may not add incremental validity to differentiating individuals who do and do not meet a clinically relevant threshold for NSSID. However, most existing studies on NSSID criteria have predominantly focused on evaluating frequency and recency criteria only or have evaluated the criterion set as a whole (e.g., Andover, 2014; Washburn et  al., 2015; Zetterqvist et  al., 2013), reporting on Criterion B descriptively. The inconsistent methodologies and lack of a planned evaluation of Criterion B’s usefulness to diagnostically differentiating NSSI groups compromises the conclusions that can be drawn about the clinical utility of Criterion B at this point. Only one known study has specifically examined Criterion B, which examined functions of NSSI in two different samples –​college undergraduates and adolescent and adult patients. At least one function for NSSI was overwhelmingly reported across both samples (99%) in this study, and the authors concluded that endorsement of functions for NSSI seems to be a universal feature regardless of frequency (Brausch et al., 2016). In two studies that evaluated new assessments of NSSI Disorder, one self-​report (Victor, Davis, & Klonsky, 2017) and one structured clinical interview (Gratz, Dixon-​Gordon, Chapman, & Tull, 2015), the percentage of individuals meeting Criterion B was large, ranging from 81% to 83%. Taken together, the general consensus from existing literature is that individuals who meet Criterion A minimums for frequency and recency of NSSI overwhelmingly report functions for their NSSI that fall under the proposed Criterion B, and do not reliably differentiate individuals meeting NSSID criteria from those who do not. Suggestions for revising Criterion B include specifying a minimum number of functions, including more specific functions within the three broad categories currently in DSM-​5, or simply incorporating the functional nature of NSSI behavior in Criterion A. Future research evaluating these ideas and their impact on Criterion B and the overall criterion set is needed to make more conclusive recommendations.

Criteria: C, D, and F Some empirical studies have also examined the remaining criterion for NSSID, either as part of an overall investigation of NSSID criteria, or specifically evaluating one or more of these. Criterion C requires that individuals must report one or more of the following experiences before engaging in NSSI:  interpersonal difficulties, negative thoughts or feelings, preoccupations with NSSI that are hard to control, and frequent thoughts about NSSI. One study that examined NSSID criteria in a sample of adolescent inpatients from Germany

Diagnostic Classification of NSSI  77

and Switzerland found that less than 50% of the sample reported preoccupation with NSSI and difficulty resisting the urge to self-​injure (In-​Albon et al., 2013). In another study of NSSID criteria, adults across two samples who met Criterion A and Criterion B were rarely excluded from the overall diagnostic group due to Criterion C. In both samples, only one participant was excluded due to not meeting Criterion C, providing further evidence that Criterion C on its own may not be helpful in differentiating clinically significant NSSI from subthreshold NSSI (Victor et al., 2017). Similar to the prevalence of reporting functions for NSSI related to Criterion B, psychological precipitants to NSSI are also reported to overwhelmingly occur –​up to 98.5% in one sample –​also calling into question the clinical utility of Criterion C (Zetterqvist et al., 2013). Similar rates of endorsement for precipitants of NSSI or thoughts about NSSI were found in a large sample of adolescent and adult psychiatric patients, with 91.3% reporting at least one experience from Criterion C and 80% reporting at least two experiences (Washburn et al., 2015). Moreover, in this sample, only 1.8% of individuals were excluded from the NSSID diagnosis due to failure to meet Criterion C. Criterion D states that NSSI includes behavior that is not socially sanctioned and is not limited to picking scabs or nail-​biting. Only a handful of studies have reported specific statistics for Criterion D, with most noting that the majority of individuals who meet other criteria for NSSID report common forms of NSSI (e.g., cutting, burning, hitting) and very few only report behaviors like nail-​biting or skin-​picking (Victor et  al., 2017). For studies that do report on Criterion D specifically, between 91% and 99% of self-​injurers in various samples meet the criterion (Gratz et al., 2015; Victor et al., 2017). Therefore, it seems rare for individuals to only engage in minor self-​injurious behaviors such as these with the intent of direct self-​harm. Somewhat related to Criterion D is Criterion F, which states that NSSI does not occur exclusively during psychosis, delirium, substance abuse or withdrawal, and is not better explained by another disorder. In a sample of adult outpatients meeting other criteria for NSSID, none of them were also diagnosed with trichotillomania (hair pulling) or stereotypic movement disorder, providing evidence that NSSI was not better accounted for by those disorders and does represent a distinct clinical issue (Selby et al., 2012). Only 0.8% of adolescent and adult patients with NSSI were excluded from NSSID due to other diagnoses (autism spectrum disorder and drug withdrawal; Washburn et al., 2015). These criteria do appear useful for diagnostic purposes to help clinicians identify clear NSSI behavior and to rule out other potential disorders.

Impairment and Distress: Criterion E Criterion E is commonly found in DSM-​5 diagnostic criteria across disorders, and in this case notes that NSSI must cause significant distress or impairment in interpersonal, academic, or social functioning. Interestingly, of all the proposed

78  Amy Brausch

criteria for NSSID, research on Criterion E has produced the most mixed results. Studies report a wide range of self-​injuring individuals meeting Criterion E, from 25% to 98% (In-​Albon et al., 2013; Washburn et al., 2015). However, this criterion has been conceptualized and assessed in numerous ways, likely contributing to the mixed findings. Overall, it is somewhat unclear how often self-​ injurers perceive distress and/​or impairment directly resulting from their NSSI. When distress and impairment are assessed indirectly by proxy variables, self-​ injurers who meet other NSSID criteria also show more distress and impairment compared to self-​injurers or clinical controls who do not meet criteria for NSSID. For example, one study investigating NSSID in a sample of adolescent inpatients used past month suicide ideation and attempts, emotion dysregulation, and loneliness as proxy measures of distress and impairment (Glenn & Klonsky, 2013). Adolescents meeting NSSID criteria were more likely to have past month suicide ideation and attempts compared to a control group that included adolescents with subthreshold NSSI and no NSSI history.The NSSID group also reported greater emotion dysregulation and loneliness than the control group, all of which the authors interpreted as representing greater impairment and distress. Similarly, a study evaluating NSSID in an undergraduate sample used suicide ideation and attempts, coping and emotion regulation skills, and resilience as proxies for impairment, and life satisfaction and social support as proxies for distress (Muehlenkamp & Brausch, 2016).This study found that individuals with recent NSSI reported more psychopathology as well as lower life satisfaction and social support (i.e., more distress), and less adaptive coping, lower resilience, and more suicide ideation and attempts compared to controls. The same pattern of differences was found when comparing individuals with 10+ acts of NSSI in the past year compared to individuals with 1–​9 acts in the past year. Washburn et al. (2015) assessed Criterion E by using Global Assessment of Functioning (GAF) scores from patients’ clinical charts. Using a cut-​off of a GAF score below 50 to indicate significant impairment and distress, this study found that 98% of individuals with current NSSI met Criterion E. In contrast to this approach, other studies have attempted to directly measure the distress and impairment criterion. While the proxy approach seems to indicate that the vast majority of individuals meeting criteria for NSSID also have significant distress and impairment compared to those with subthreshold NSSI or no NSSI, direct assessment of these constructs produces different results. In a community sample of adolescents, among those meeting criteria for NSSID, 23% denied distress and 7.8% denied impairment (Zetterqvist et  al., 2013). Items in this study directly assessed distress and impairment with questions like, “Has the self-​injurious behavior caused you distress?” and “Has the self-​ injurious behavior affected your schooling/​interpersonal relationships/​leisure time?” A similar study of adolescent inpatients found that 69% of those meeting NSSID criteria responded affirmatively to questions about distress related to NSSI, and impairment at leisure time was the most commonly endorsed item regarding impairment (In-​Albon et  al., 2013). Among adolescents with

Diagnostic Classification of NSSI  79

repetitive, recent NSSI, 29% denied both distress and impairment. Interestingly, almost 80% of those meeting NSSID also indicated that they wanted help, and 30% of adolescents who denied impairment and distress also expressed that they wanted help. This item was added to better operationalize distress and impairment associated with NSSI. In a community sample of adults, impairment and distress were assessed with the questions, “Does NSSI interfere with your functioning?” and “Do you want to stop engaging in NSSI?” (Andover, 2014). While close to 65% of all individuals with NSSI history responded positively to either or both of these questions, 24% of individuals responded to the question about stopping NSSI with “I don’t know.” Only 8.8% of individuals with NSSI history reported that the NSSI behavior interferes with functioning, but those meeting NSSID criteria were more likely to report interference in functioning than those not meeting criteria, and both groups were equally likely to want to stop NSSI engagement. In another study of college students with NSSI history, only 12% indicated a desire to stop self-​injuring, and individuals in that group reported significantly lower lifetime NSSI frequency compared to individuals who reported no desire to stop (Engle & Brausch, 2017). Based on these two studies, a desire to stop self-​injuring may be indicative of less severe behavior, but more research is needed on this particular NSSI feature to be more conclusive. A handful of studies have more directly assessed the distress and impairment criterion, providing additional data on how well Criterion E helps distinguish between clinical and subclinical NSSI behavior. In a follow-​up study to Zetterqvist et al. (2013), more comparisons were made between adolescents meeting all NSSID criteria, adolescents with NSSI on five or more days in the past year but not meeting other NSSID criteria, and adolescents who met all criteria for NSSID except for Criterion E (denied impairment or distress) (Zetterqvist, 2017). Adolescents meeting NSSID criteria and adolescents meeting all but Criterion E were similar on demographics and NSSI features; however, those denying distress and impairment were less likely to report suicide attempts and had a later age of onset for NSSI than those meeting full criteria. The no distress/​impairment group also had fewer anxiety and trauma symptoms, as well as fewer interpersonal negative events. Gratz and colleagues (2015) developed a structured clinical interview for assessing NSSID, including questions specifically about distress and impairment. With their sample of self-​ injuring individuals, aside from Criterion A, Criterion E was least likely to be met (only 41%). When examining the association between all criteria and clinical characteristics of NSSI and related psychopathology, Criterion E emerged as the only criterion to be uniquely associated with number of NSSI methods used, intrapersonal functions, emotion dysregulation and depression and anxiety symptoms. The authors concluded that most individuals with recurrent, recent self-​injury tend to meet most criteria for NSSI, but that Criterion E appears to have diagnostic significance. Similarly, Victor and colleagues (2017) developed a self-​report measure assessing the proposed NSSID criteria and came to similar conclusions. In their two-​sample study of undergraduate students with NSSI

80  Amy Brausch

history, individuals were excluded from an NSSID diagnosis most frequently for failing to meet Criteria A and E. Distress was more prevalent than impairment in both samples and was reported by 45% in one sample and only 20% in the other. Just as in the Gratz et al. (2015) study, a large proportion of individuals meeting Criterion A did not report distress or impairment. It is surprising to find so much empirical investigation into Criterion E for NSSID when this particular criterion appears so frequently in the DSM-​5 across disorders and represents part of the overall definition of abnormal behavior or psychopathology. It is well established that individuals who engage in NSSI also exhibit more markers of overall distress and impairment, such as emotion dysregulation, more symptoms of stress, depression, and anxiety, and more suicide ideation and behaviors compared to individuals with no NSSI behavior (Nock, 2010). We see similar patterns when comparing individuals who meet NSSID criteria compared to those with subthreshold NSSI. It is also well known that these markers of distress and impairment are associated with NSSI behavior itself, sometimes preceding its onset, or occurring concurrently. If impairment and distress are operationalized in this manner, it seems that Criterion E does not add much to the differentiation of clinical versus subclinical NSSI. If Criterion E is operationalized as an individual’s perception of experiencing distress and impairment as a direct result of engaging in NSSI, then it may be quite useful in helping to distinguish clinical severity. Burke and colleagues (2017) attempted to assess the impact of NSSI behavior specifically with the creation of a scale to measure the social, behavioral, and emotional consequences of engaging in NSSI. In creating this new scale, they drew upon prior research that finds shame and guilt to be associated with NSSI behavior, NSSI behavior negatively affecting interpersonal relationships, and that NSSI behavior often leads to scarring and feelings of having a “marker of stigma or shame” (Bachtelle & Pepper, 2015; Briere & Gill, 1998; Deliberto & Nock, 2008).The results of this initial validation study in a sample of undergraduates with NSSI history found that this new measure reliably assesses the overall impact of NSSI; it was also associated with markers of NSSI severity, indicating that individuals who endorsed impairment directly due to their NSSI also had more severe features of NSSI, greater suicide attempt history, and more emotional reactivity. Interestingly, from a clinical perspective, less than 50% of clinicians surveyed on the proposed NSSID criteria rated Criterion E as a prototypic symptom (Lengel & Mullins-​Sweatt, 2013). All of these findings beg the question: is an individual with recent, frequent, recurrent NSSI that reportedly serves a function and is typically preceded by an emotional state or interpersonal event, but is reported to cause no distress or impairment, clinically different from an individual who does report distress and impairment? Are we comfortable relying on self-​perceptions of distress and impairment and using those as the deciding factor in making a diagnosis? There are many questions that remain to be answered concerning Criterion E. In the meantime, however, Criterion E seems to be one of the few proposed criteria that effectively discriminates potential severity of NSSI.

Diagnostic Classification of NSSI  81

The Problem with Cut-​O ffs and Alternatives to Diagnosis Even though most of the existing literature on NSSID is supportive of the recognition of NSSI as a separate disorder and its inclusion in the DSM, it is important to point out a few critical issues. The first issue is most relevant to Criterion A and the idea of establishing what could be interpreted as arbitrary cut-​offs for frequency and recency thresholds (Shaffer & Jacobson, 2009). How do we reliably know that NSSI occurring on five days in the past 12 months is more clinically concerning than NSSI occurring on three days in the same time frame? How do we know that 25 or more days is more clinically meaningful than ten? Existing research on NSSI does provide insight into what might be a threshold for clinically significant NSSI frequency, such as the aforementioned studies that used empirically derived cut-​ points using statistical techniques (Ammerman et  al., 2017; Muehlenkamp & Brausch, 2016; Muehlenkamp et al., 2017). Other research has found greater psychopathology and concurrent risk behaviors as NSSI frequency increases (e.g., Brausch & Boone, 2015). On the other hand, a curvilinear analyses of NSSI frequency found that negative outcomes associated with NSSI in terms of psychopathology and suicide risk seem to “level off ” around a frequency of 50 (Paul, Tsypes, Eidlitz, Ernhout, & Whitlock, 2015). Most researchers and clinicians would agree that more frequent and severe NSSI is associated with greater clinical concern, distress, impairment, psychopathology, and suicide risk. The challenge is to identify a cut-​off that makes sense both empirically and clinically, and that reliably identifies individuals who are engaging in NSSI that is clinically significant. The dichotomous and categorical nature of most DSM-​5 disorder diagnostic criteria has been criticized throughout its history. In the newest edition, it is evident that some workgroups advocated for and facilitated revisions to existing disorder categories to reflect a more dimensional approach, such as autism spectrum disorder and schizophrenia. A similar approach could be used for NSSID, with levels of severity that include things like frequency, recency, duration of NSSI, severity of injury, experience (or lack) of pain, number of NSSI methods used, age of onset, scarring, shame, guilt and other negative affect resulting directly from the NSSI, functions for the NSSI, desire to stop self-​injuring, etc. These are all factors that have been identified as being associated with more severe NSSI, and may serve to better identify clinically significant cases, as well as distinguishing mild NSSID from subthreshold NSSID (Andover, 2014; Gratz et al., 2015; Washburn et al., 2015). Another option for the DSM-​5 is to create an NSSI specifier that can be added onto multiple disorders instead of creating a separate NSSID. Just as many disorders can apply specifiers such as “with catatonia” or “with p­ sychotic features” or “acute vs. chronic,” perhaps a new specifier could be “with  NSSI.”  We could then have diagnoses such as major depressive disorder with NSSI, generalized anxiety with NSSI, post​ traumatic stress disorder (PTSD) with

82  Amy Brausch

NSSI, bulimia nervosa with NSSI, etc.Yet another option is to include NSSI as a V-​code that can also be added on to other diagnoses. The downside for both of these alternatives is that it would still not apply to individuals who do not meet criteria for any other disorders and only present with symptoms consistent with NSSID.

Importance and Utility of Having an NSSID Diagnosis Even though existing evidence is mixed regarding individual criteria for NSSID, there are several benefits to having an NSSID diagnosis. The DSM-​5 introduction states that “the most important standard for the DSM-​5 disorder criteria will be their clinical utility for the assessment of clinical course and treatment response of individuals grouped by a given set of diagnostic criteria” (APA, 2013, p.  20). As Selby and colleagues (2015) noted in their review of evidence for NSSID diagnostic validity and remaining obstacles, “the central question should be whether the inclusion of a disorder will result in meaningful improvements in the assessment and treatment of a behavior that causes significant impairment” (p. 88). Selby et al. (2015) concluded that including NSSID as a separate disorder will result in clinical improvements. Across many studies and reviews, there is agreement that NSSID will provide the following benefits: (1) establish a definition for clinically significant NSSI that will be consistent for use in diagnosis and research; (2) provide better assessment of NSSI; (3) increase quantity and quality of NSSI research; and (4) promote the development of and research on effective treatments for NSSI. First, research on NSSI has been long afflicted with various labels for the behavior itself (e.g., self-​mutilation, deliberate self-​harm, self-​injurious behavior, etc.) and slightly varying definitions that have the potential to cause confusion among researchers and clinicians alike (Muehlenkamp, 2005). Historically, patients with NSSI have been misdiagnosed as having BPD, and individuals with NSSI often report that their self-​injury is assumed to be a suicide attempt (Glenn & Klonsky, 2013; Kumar, Pepe, & Steer, 2004; Shaffer & Jacobson, 2009). Establishing NSSI as a disorder with clear diagnostic criteria will improve communication about NSSI not only between clinicians and patients, but also between researchers and clinicians. Having a separate diagnosis for NSSI may also help reduce bias among clinicians who automatically consider BPD when NSSI behavior is present, which will hopefully improve differential diagnosis and decrease misdiagnosis (Butler & Malone, 2013; Wilkinson & Goodyer, 2011). Second, when diagnostic criteria are established for NSSID, it is likely that more specific measures will be developed to assess and screen for the disorder. As noted, a few measures have been developed to assess the proposed criteria for NSSID, but only two appear to assess all criteria: the Clinician-​Administered Nonsuicidal Self-​Injury Disorder Index (Gratz et al., 2015) and the Nonsuicidal Self-​Injury Disorder Scale (NSSIDS; Victor et  al., 2017). The initial validation papers on both of these measures provide valuable information regarding prevalence rates

Diagnostic Classification of NSSI  83

of individuals meeting all proposed criteria for NSSID, and also which criteria appear to provide the most sensitivity for meeting diagnostic thresholds. Prior to the availability of these measures, researchers relied on existing self-​ report measures of NSSI, such as the Inventory of Statements About Self-​Injury (Klonsky & Glenn, 2009), the Functional Assessment of Self-​Mutilation (Lloyd, Kelley, & Hope, 1997), the Deliberate Self-​Harm Inventory (Gratz, 2001), and the Self-​Injurious Thoughts and Behaviors Interview (Nock et al., 2007). While all of these measures provide a thorough assessment of NSSI behavior and its features, all of them predate the NSSID proposed criteria and, as such, do not directly measure all diagnostic criteria. Research thus far has largely been based on variables that are “close enough” to diagnostic criteria, such as frequency of NSSI acts rather than number of days on which NSSI occurs (Criterion A), or that use proxy variables rather than direct assessment (mostly seen with distress and impairment criteria). NSSID criteria will greatly enhance assessment of NSSI across disciplines and settings and will propel forward research to establish more accurate prevalence rates for NSSID across populations (Selby et al., 2015). Third, once NSSID criteria are firmly established, research on NSSI is likely to flourish, with increases in both quality and quantity. As noted, the criteria will provide a standard and consistent definition of NSSI that researchers can embrace, helping to unite research on this disorder. Because NSSI is not currently a disorder in the DSM, it is often left out of large, epidemiological studies or long-​term longitudinal cohort studies (Selby et  al., 2015). Because of this omission, research on NSSI is in danger of stalling. A DSM diagnosis would spur NSSID’s inclusion in large-​scale studies, replication studies, and would hopefully be met with an increase in research funding to better understand this new diagnosis (Butler & Malone, 2013; Wilkinson & Goodyer, 2011). Fourth, having an NSSID diagnosis would propel treatment development and effectiveness research on treatments specifically for NSSI. The lack of empirically supported treatments that focus on NSSI behavior remains a large hole in the overall field, and leaves clinicians with little direction on how to best treat NSSI. Several reviews of treatment for NSSI have pointed out the lack of empirical evidence for existing treatments in their effectiveness for reducing NSSI, and the dire need for treatment development and clinical research on new and existing treatments (Brausch & Girresch, 2012; Muehlenkamp, 2006; Nock, 2010). It should also be noted that many studies on treatment effectiveness for NSSI are conducted within the context of BPD, which does not necessarily generalize to individuals with NSSI but few to no BPD symptoms. Having an NSSID diagnosis would promote treatment development with NSSI as a target, rather than relying on existing treatments to indirectly affect NSSI behavior, such as problem-​solving therapy, cognitive or behavioral treatment, or dialectical behavior therapy (Brausch & Girresch, 2012; Selby et al., 2015). Moreover, as managed care systems are more and more likely to require a DSM diagnosis to reimburse for treatment, including NSSID in the DSM would ensure coverage of NSSI treatment, especially for individuals who do not meet diagnostic

84  Amy Brausch

criteria for any other disorders (Selby et al., 2015). Given that NSSI behavior is associated with increased risk for suicide ideation and behaviors, establishing and validating treatments for NSSI may help with suicide prevention as well.

Conclusion Taken together, a unified definition of NSSI will improve communication about and diagnosis of NSSID, it will enhance research on the disorder, and all these benefits will also advance treatment development, implementation, and evaluation for NSSI-​specific treatment techniques. The establishment of NSSID has already spurred research on clinically significant NSSI and how to best define and assess it. It is anticipated that this research trend will continue, as more studies set out to evaluate and hone the proposed DSM-​5 criteria. The field can remain hopeful that continued empirical work will result in an improved NSSID diagnosis that will in fact result in meaningful advancements in the assessment and treatment of NSSI.

References American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington,VA: American Psychiatric Publishing. Ammerman, B. A., Jacobucci, R., Kleiman, E. M., Muehlenkamp, J. J., & McCloskey, M.  S. (2017). Development and validation of empirically derived frequency criteria for NSSI Disorder using exploratory data mining. Psychological Assessment, 29, 221–​231. Andover, M.  S. (2014). Non-​suicidal self-​injury disorder in a community sample of adults. Psychiatry Research, 219, 305–​310. Bachtelle, S.  E., & Pepper, C.  M. (2015). The physical results of nonsuicidal self-​ injury: The meaning behind the scars. The Journal of Nervous and Mental Disease, 203 (12), 927–​933. Barrocas, A. L., Hankin, B. L.,Young, J. F., & Abela, J. R. Z. (2012). Rates of nonsuicidal self-​ injury in youth:  Age, sex, and behavioral methods in a community sample. Pediatrics, 130, 39–​45. Brausch, A.  M., & Boone, S.  D. (2015). Frequency of non-​ suicidal self-​ injury in adolescents: Differences in suicide attempts and other risk behaviors. Suicide and Life-​ Threatening Behavior, 45, 612–​622. Brausch, A.  M., & Girresch, S.  K. (2012). A review of empirical treatment studies for adolescent nonsuicidal self-​injury. Journal of Cognitive Psychotherapy:  An International Quarterly, 26, 3–​18. Brausch, A.  M., Muehlenkamp, J.  J., & Washburn, J.  J. (2016). Nonsuicidal self-​ injury disorder: Does Criterion B add diagnostic utility? Psychiatry Research, 244, 179–​184. Briere, J., & Gil, E. (1998). Self-​mutilation in clinical and general population samples: Prevalence, correlates, and functions. American Journal of Orthopsychiatry, 68, 609–​620. Burke, T.  A., Ammerman, B.  A., Hamilton, J.  L., & Alloy, L.  B. (2017). Impact of Nonsuicidal Self-​ Injury Scale:  Initial psychometric validation. Cognitive Therapy Research, 41, 130–​142.

Diagnostic Classification of NSSI  85 Butler, A.  M., & Malone, K. (2013). Attempted suicide v.  non-​ suicidal self-​ injury: Behavior, syndrome or diagnosis? The British Journal of Psychiatry, 202, 324–​325. Claes, L., & Muehlenkamp, J.  J. (2014). Non-​ suicidal self-​ injury in eating disorders: Advancements in etiology and treatment. New York, NY: Springer. Deliberto, T. L., & Nock, M. K. (2008). An exploratory study of correlates, onset, and offset of non-​suicidal self-​injury. Archives of Suicide Research, 12, 219–​231. Engle, A., & Brausch, A. M. (2017). Cessation of nonsuicidal self-​injury: How do those who desire to stop differ from those who do not? Poster presentation at the Association of Behavioral and Cognitive Therapies, San Diego, CA. Favazza, A. R., & Rosenthal, R. J. (1993). Diagnostic issues in self-​mutilation. Psychiatric Services, 44, 134–​140. Ghaziuddin, M.,Tsai, L., Naylor, M., & Ghaziuddin, N. (1992). Mood disorder in a group of self-​cutting adolescents. Acta Paedopsychiatrica, 55, 103–​105. Glenn, C. R., & Klonsky, E. D. (2013). Nonsuicidal Self-​Injury Disorder: An empirical investigation in adolescent psychiatric patients. Journal of Clinical Child & Adolescent Psychology, 42, 496–​507. Graff, H., & Mallin, R. (1967). The syndrome of the wrist cutter. American Journal of Psychiatry, 124, 36–​42. Gratz, K.  L. (2001). Measurement of deliberate self-​harm:  Preliminary data on the Deliberate Self-​Harm Inventory. Journal of Psychopathology and Behavioral Assessment, 23, I253–​263. Gratz, K. L., Dixon-​Gordon, K. L., Chapman, A. L., & Tull, M. T. (2015). Diagnosis and characterization of DSM-​ 5 Nonsuicidal Self-​ Injury Disorder using the clinician-​ administered Nonsuicidal Self-​ Injury Disorder Index. Assessment, 22, 527–​539. In-​Albon, T., Ruf, C., & Schmid, M. (2013). Proposed diagnostic criteria for the DSM-​5 of non-​suicidal self-​injury in female adolescents:  Diagnostic and clinical correlates. Psychiatry Journal, doi:10.1155/​2013/​159208 Klonsky, E. D. (2007). The functions of deliberate self-​injury: A review of the evidence. Clinical Psychological Review, 27, 226–​239. Klonsky, E.  D., & Glenn, C.  R. (2009). Assessing the functions of non-​suicidal self-​ injury:  Psychometric properties of the Inventory of Statements about Self-​injury (ISAS). Journal of Psychopathology and Behavioral Assessment, 31, 215–​219. Kumar, G., Pepe, D., & Steer, R.  A. (2004). Adolescent psychiatric inpatients’ self-​ reported reasons for cutting themselves. The Journal of Nervous and Mental Disease, 12, 830–​836. Lengel, G. J., & Mullins-​Sweatt, S. N. (2013). Nonsuicidal self-​injury disorder: Clinician and expert ratings. Psychiatry Research, 210, 940–​944. Lloyd, E. E., Kelley, M. L., & Hope, T. (1997). Self-​mutilation in a community sample of adolescents: Descriptive characteristics and provisional prevalence rates. Poster session at the annual meeting of the Society for Behavioral Medicine, New Orleans, LA. Lloyd-​Richardson, E. E., Perrine, N., Dierker, L., & Kelley, M. L. (2007). Characteristics and functions of non-​ suicidal self-​ injury in a community sample of adolescents. Psychological Medicine, 37, 1183–​1192. Muehlenkamp, J.  J. (2005). Self-​ injurious behavior as a separate clinical syndrome. American Journal of Orthopsychiatry, 75, 324–​333. Muehlenkamp, J.  J. (2006). Empirically supported treatments and general therapy guidelines  for non-​suicidal self-​injury. Journal of Mental Health Counseling, 28(2), 166–​185.

86  Amy Brausch Muehlenkamp, J. J., & Brausch, A. M. (2016). Reconsidering Criterion A for the diagnosis of Non-​Suicidal Self-​Injury Disorder. Journal of Psychopathology and Behavioral Assessment, 38, 547–​558. Muehlenkamp, J.  J., Brausch, A.  M., & Washburn, J.  J. (2017). How much is enough? Examining frequency criteria for NSSI Disorder in adolescent inpatients. Journal of Consulting & Clinical Psychology, 85, 611–​619. Nock, M. K. (2010). Self-​injury. Annual Review of Clinical Psychology, 6, 339–​363. Nock, M.  K., Holmberg, E.  B., Photos, V.  I., & Michel, B.  D. (2007). Self-​injurious thoughts and behaviors interview: Development, reliability, and validity in an adolescent sample. Psychological Assessment, 19, 309–​317. Pao, P. (1969). The syndrome of delicate self-​cutting. Psychology and Psychotherapy: Theory, Research and Practice, 42, 195–​206. Paul, E., Tsypes, A., Eidlitz, L., Ernhout, C., & Whitlock, J. (2015). Frequency and functions of non-​suicidal self-​injury: Associations with suicidal thoughts and behaviors. Psychiatry Research, 225, 276–​282. Plener, P.  L., Allroggen, M., Kapusta, N.  D., Brahler, E., Fegert, J.  M., & Groschwitz, R.  C.  (2016). The prevalence of Nonsuicidal Self-​Injury (NSSI) in a representative sample of the German population. BMC Psychiatry, 16, 353–​360. Regier, D. A., Narrow, W. E., Clarke, D. E., Kraemer, H. C., Kuramoto, S. J., Kuhl, E. A., & Kupfer, D. J. (2013). DSM-​5 field trials in the United States and Canada, Part II: Test–​ retest reliability of selected categorical diagnoses. American Journal of Psychiatry, 170,  59–​70. Ross, S., & Heath, N. (2002). A study of the frequency of self-​mutilation in a community sample of adolescent. Journal of Youth and Adolescence, 31, 67–​77. Selby, E. A., Bender, T. W., Gordon, K. H., Nock, M. K., & Joiner, T. E., Jr. (2012). Non-​ Suicidal Self-​Injury (NSSI) Disorder: A preliminary study. Personality Disorders: Theory, Research, and Treatment, 3, 167–​175. Selby, E. A., Kranzler, A., Fehling, K. B., & Panza, E. (2015). Nonsuicidal self-​injury disorder: The path to diagnostic validity and final obstacles. Clinical Psychology Review, 38,  79–​91. Shaffer, D., & Jacobson, C. (2009). Proposal to the DSM-​V childhood and mood disorder work groups to include non-​suicidal self-​injury (NSSI) as a DSM-​V disorder. American Psychiatric Association. Suyemoto, K. L. (1998). The functions of self-​mutilation. Clinical Psychology Review, 18, 531–​554. Turner, B.  J., Chapman, A.  L., & Layden, B.  K. (2012). Intrapersonal and interpersonal functions of non-​suicidal self-​injury:  Associations with emotional and social functioning. Suicide and Life-​Threatening Behavior, 42, 36–​55. Victor, S.  E., Davis, T., & Klonsky, E.  D. (2017). Descriptive characteristics and initial ­psychometric properties of the Non-​Suicidal Self-​Injury Disorder Scale. Archives of Suicide Research, 21, 265–​278. Washburn, J. J., Potthoff, L. M., Juzwin, K. R., & Styer, D. M. (2015). Assessing DSM-​ 5 Nonsuicidal Self-​ Injury Disorder in a clinical sample. Psychological Assessment, 27,  31–​41. Wilkinson, P., & Goodyer, I. (2011). Non-​suicidal self-​injury. European Child and Adolescent Psychiatry, 20, 103–​108. World Health Organization. (2018). MB23.E Non-​ suicidal self-​ injury. International Classification of Disease, 11th Revision. Retrieved from https://​icd.who.int/​dev11/​l-​m/​ en#/​http://​id.who.int/​icd/​entity/​1430296724

Diagnostic Classification of NSSI  87 Zetterqvist, M. (2017). Nonsuicidal self-​injury in adolescents:  Characterization of the disorder and the issue of distress and impairment. Suicide and Life-​Threatening Behavior, 47, 321–​335. Zetterqvist, M., Lundh, L.  G., Dahlstrom, O., & Svedin, C.  G. (2013). Prevalence and function of non-​suicidal self-​injury in a community sample of adolescents, using suggested DSM-​5 criteria for a potential NSSI Disorder. Journal of Abnormal Child Psychology, 41, 759–​773.

Chapter 6

Nonsuicidal Self-​I njury and Compulsive Disorders Justyna Jurska,Vincent Corcoran, and Margaret Andover

NSSI and Compulsive Disorders Nonsuicidal self-​injury (NSSI) encompasses a range of self-​injurious behaviors; common methods include cutting, scraping, carving, self-​hitting, skin-​picking, self-​biting, and interfering with wound healing (Klonsky, 2007), but most individuals engage in more than one method of NSSI (Glenn & Klonsky, 2011).The last two decades have clarified the reasons people engage in NSSI. Researchers have classified NSSI functions as falling on two superordinate factors: intrapersonal (automatic) and interpersonal (social; Klonsky & Glenn, 2009; Nock & Prinstein, 2004). Intrapersonal factors focus on self-​reinforcement and include emotion regulation, self-​punishment, and marking distress (Klonsky & Glenn, 2009). Interpersonal factors focus on reinforcement from others or the environment, such as interpersonal influence, peer bonding, and communication (Klonsky & Glenn, 2009). Affect regulation is the most commonly endorsed function of the behavior (Klonksy, 2009); NSSI has been shown to temporarily alleviate negative emotion and affective arousal. Similar to NSSI, compulsive behaviors are performed primarily to reduce negative affect and are maintained by negative reinforcement (e.g., McKay & Andover, 2012; Najmi, Kuckertz, & Amir, 2010). This chapter reviews the literature on the association between NSSI and compulsive disorders, including obsessive compulsive disorder (OCD) and obsessive-​compulsive and related disorders (OCRDs). Special focus is given to their comorbidity, distinctions and overlap in characteristics, treatment response, and neurobiology/​neurochemistry. Further, we explore the compulsive nature of some NSSI behaviors, and finally provide recommendations for researchers and clinicians.

Obsessive Compulsive Disorder and NSSI Although NSSI behaviors are only included in the DSM-​5 as a symptom of borderline personality disorder (BPD; American Psychiatric Association [APA], 2013), NSSI is understood to occur transdiagnostically (Nock, Joiner, Gordon, Lloyd-​Richardson, & Prinstein, 2006). NSSI co-​occurs with many psychiatric

NSSI and Compulsive Disorders  89

disorders, including major depression (Nitkowski & Petermann, 2011), anxiety disorders, such as post​traumatic stress disorder (Jacobson, Muehlenkamp, Miller, & Turner, 2008) and generalized anxiety disorder (Nock et  al., 2006), eating disorders (Jacobson & Luik, 2014), and substance use disorders (Garisch & Wilson,  2015). Comorbidity between NSSI and disorders on the obsessive-​compulsive spectrum has also garnered research interest (e.g., McKay, Kulchycky, & Danyko, 2000). Individuals diagnosed with BPD who engaged in NSSI report significantly more OCD symptoms, including obsessions and compulsions, than patients with BPD without a NSSI history (McKay et al., 2000). NSSI co-​occurs with OCD outside a BPD diagnosis as well (Washburn, Gebhardt, Styer, Juzwin, & Gottlieb, 2012). Approximately 4% of psychiatric inpatients and outpatients with NSSI are diagnosed with OCD (Washburn et al., 2012), and adolescents with OCD are 5.3 times more likely to engage in NSSI than those without OCD (Garrison et al., 1993). In addition to the small body of literature on the association between OCD and NSSI, researchers have investigated the association between OCD and skin-​picking specifically, a commonly reported method of NSSI. Individuals who engage in repetitive skin-​picking report significantly higher rates of co-​ occurring OCD (6–​52%; Arnold et al., 1998; Wilhelm et al., 1999) than adults in the general population. Among individuals with OCD, rates of self-​injurious skin-​picking range from 8.9% to 24% (Cullen et  al., 2001; Grant, Mancebo, Pinto, Eisen, & Rasmussen, 2006). The overlap between NSSI and OCD is evident beyond rates of co-​occurrence and includes basic characteristics and topography (McKay & Andover, 2012). Both compulsions in OCD and some NSSI methods, such as skin-​picking, tend to be repetitive and habitual in nature (McKay & Andover, 2012). Individuals with OCD may feel compelled to perform compulsions, even when they recognize that they are excessive or unreasonable (Abramowitz, Taylor, & McKay, 2009). Likewise, individuals with NSSI may find their urges hard to resist (Nixon, Cloutier, & Aggarwal, 2002; Washburn, Juzwin, Styer, & Aldridge, 2010) and their self-​injurious behaviors difficult to stop or decrease (Hasking et al., 2016). Further, compulsions in OCD may be performed according to rigid, self-​set rules (Abramowitz, McKay, & Taylor, 2008). Similarly, some methods of NSSI might resemble ritualized behaviors, as NSSI may be enacted under specific circumstances, on specific body areas, and with preferred means (Simeon & Favazza, 2001). Further, NSSI and OCD are maintained by similar principles of reinforcement. For instance, individuals with OCD experience obsessions, or intrusive thoughts, impulses, and images, which contribute to significant distress or anxiety. In an effort to neutralize or suppress these thoughts and reduce anxiety, they may engage in compulsions, which are circumscribed behaviors or mental acts (APA, 2013). Like obsessions in OCD, certain thoughts or urges in the context of NSSI may be experienced as unwanted or intrusive by the individual,

90  Justyna Jurska et al.

who may actively attempt to suppress them with varying degree of success (e.g., Najmi, Wegner, & Nock, 2007). Similarly, it is common for individuals with NSSI to experience heightened distressing thoughts and emotions (Klonsky, Muehlenkamp, Lewis, & Walsh, 2011). In order to terminate the aversive state, individuals may engage in NSSI as a method of affect regulation (Klonsky, 2007). Both NSSI and OCD are associated with feelings of tension or anxiety prior to the self-​injurious or compulsive act, followed by decreased discomfort (Abramowitz et al., 2009; Klonsky, 2009), which negatively reinforces the behaviors. NSSI and compulsions are similar in their ability to regulate states of arousal and affect and to produce a momentary sense of relief. Despite similarities between compulsive NSSI and OCD, there are several distinctions between them. First, although the prevalence of OCD among individuals who skin-​pick suggests a relationship between the behaviors, comorbidity between OCD and other disorders is also common, particularly with many anxiety disorders and major depression (Nestadt et al., 2001). Second, although OCD and NSSI may involve repetitive or compulsive behaviors, individuals with OCD may not present with compulsions. In addition, they may engage in compulsive mental acts rather than physical behaviors (Abramowitz et al., 2009). Third, individuals with OCD may experience compulsions that are performed to prevent or reduce the chance of a feared outcome (Abramowitz et al., 2009), rather than to decrease negative affect or to regulate the affective experience. Fourth, in contrast to OCD, NSSI may be positively reinforcing by providing pleasurable stimulation to individuals during states of boredom or numbness (Selby, Nock, & Kranzler, 2014). Despite these distinctions, the overlap in topography and function between NSSI and OCD compulsions warrants further consideration.

Obsessive-​C ompulsive Related Disorders and NSSI In addition to OCD, several disorders have been noted to share a significant compulsivity component, prompting research into their associations with each other and OCD (Hollander & Rosen, 2000).These disorders are highly comorbid with OCD and share common symptoms, neuroanatomy, neurochemistry, and treatment response (Hollander et al., 2005). In response to this research, a new category of disorders, obsessive-​compulsive and related disorders (OCRDs), was created for the DSM-​5 (APA, 2013). OCRDs include OCD, body dysmorphic disorder (BDD), trichotillomania (TTM), hoarding disorder (HD), and excoriation (skin-​picking) disorder (SPD; APA, 2013). OCRDs are characterized by repetitive, unwanted obsessions/​preoccupations and/​or compulsions (Hollander, Braun, & Simeon, 2008). Because the diagnostic category of OCRDs is a new addition to the DSM-​5, little research has directly addressed the association between NSSI and OCRDs, although it is gaining attention in the psychiatric literature (McKay & Andover, 2012). Symptoms of several disorders in the OCRD category (including

NSSI and Compulsive Disorders  91

behaviors that have been classified in the literature as body-​focused repetitive behaviors, or BFRBs) are focused on aspects of an individual’s body or physical appearance, often resulting in an unhealthy preoccupation, functional impairment, and distress (Stein, Fineberg, & Reghunandanan, 2015). Likewise, NSSI often targets specific areas of one’s body and skin and contributes to psychosocial impairment. Like NSSI, OCRDs are maintained by negative reinforcement. For example, hair-​pulling behavior in TTM or compulsions in BDD may reduce anxiety or lead to the avoidance of perceived negative consequences (Hollander et al., 2008). Some studies have examined the association between specific OCRDs and NSSI, most commonly skin-picking. Although often thought to be a minor NSSI method, skin-​ picking can be a serious self-​ injurious behavior. Skin-​ picking is common: over 10% of community members report clinically significant skin-​picking, and 13% report that the behavior impacts their psychosocial functioning (Hayes, Storch, & Berlanga, 2009). The behavior is repetitive and occurs frequently; while individuals report skin-​picking episodes of fewer than five minutes, these episodes often total over an hour a day (Wilhelm et al., 1999). Negative consequences such as dissatisfaction with appearance, shame, embarrassment, and avoidance of social situations are commonly reported (Wilhelm et al., 1999). Skin-​picking is also associated with significant tissue damage, with the majority of individuals who skin-​pick reporting scars and infections as a result of their skin-​picking (Wilhelm et  al., 1999). Significant rates of mood, anxiety, and personality disorders have also been reported among individuals who engage in skin-​picking (Wilhelm et al., 1999). Although the recently added diagnosis of SPD will be discussed in more detail later in this chapter, skin-​ picking is included below as a method of NSSI given the severity and clinical significance of the behavior, its categorization as NSSI, and the lack of research on more diverse methods of NSSI.

Body Dysmorphic Disorder BDD is a debilitating condition in which individuals experience intrusive thoughts and preoccupations about one or more aspects of their physical appearance that they find visibly unsightly (APA, 2013). The imperfection or defect may represent only minor physical flaws or may be completely subjective. Concerns about appearance among individuals with BDD are generally accompanied by repetitive or recurrent behaviors such as mirror-​checking, excessive grooming, excessive reassurance-​seeking, and concealing with clothes or make-​ up (APA, 2013;Veale, 2001). Research on the co-​occurrence of NSSI and BDD is limited. Most research examining their association has focused primarily on skin-​picking, which co-​ occurs with BDD in 26–​45% of cases (Mufaddel, Osman, Almugaddam, & Jafferany, 2013). Conversely, BDD is diagnosed in approximately one-​ third of patients with significant skin-​picking (Wilhelm et  al., 1999) and may be

92  Justyna Jurska et al.

associated with greater frequency and duration of NSSI episodes among individuals with BPD compared to those without BDD (Semiz et al., 2008). BDD shares several similarities in basic topography and phenomenology with NSSI. First, body image devaluation and disturbance are frequently reported by those who engage in skin-​picking (Phillips & Taub, 1995). Among individuals with BDD and compulsive skin-​picking, nearly all report preoccupations involving their skin (Phillips & Taub, 1995). Just as individuals with NSSI report multiple methods of self-​injury, individuals with BDD frequently engage in compulsive and idiosyncratic behaviors, including excessive mirror-​checking and grooming rituals (Phillips, Menard, Fay, & Weisberg, 2005). Such compulsive behaviors are considered unpleasant by most and are meant to reduce BDD-​ related anxiety and negative affect (Phillips & Kaye, 2007), consistent with the affect regulation function typically found in NSSI. Despite these areas of overlap, the content of BDD obsessions and compulsions are distinct from NSSI, as they are closely tied to preoccupation with a part of the body believed to be defective or flawed. Although BDD compulsions may function to regulate affect like NSSI, BDD compulsions also serve to protect the individual. Specifically, BDD behaviors such as mirror-​checking may be better understood as monitoring and threat detection, while camouflaging and comparing self to others may function to avoid social threats such as rejection, social contempt, or ridicule (Veale & Gilbert, 2014). Finally, skin-​picking that is performed to improve the appearance of perceived flaws in BDD likely differs from skin-​picking performed for the purposes of causing pain or injury, such as with NSSI (Snorrason et  al., 2012). In sum, BDD may be more narrowly centered on body-​focused dissatisfaction and imperfections than NSSI.

Trichotillomania TTM is a psychiatric disorder marked by recurrent hair-​pulling that is not better explained by another medical or psychiatric disorder (APA, 2013). Individuals pull hair from specific areas of their body, with some individuals manipulating or ingesting the pulled hair.There is considerable variability within and between individuals in the number of hairs extracted per episode, the time spent engaging in the behavior, and the pattern of hair-​pulling (Keuthen et al., 1998). Due to its chronic nature, individuals may experience significant hair loss despite repeated efforts to decrease or stop pulling (APA, 2013). Further, the behavior is often associated with clinically significant distress and functional impairment (Woods et al., 2006). Individuals with TTM may avoid or withdraw from social situations and have low self-​esteem (Soriano et al., 1996). Although attention to TTM has been increasing (Snorrason, Belleau, & Woods, 2012), studies on the association between NSSI and TTM have been sparse. Self-​ injurious behaviors are commonly reported among individuals with TTM (du Toit, van Kradenburg, Niehaus, & Stein, 2001), with 10–​34% of individuals with TTM reporting skin-​picking behavior, a rate that researchers have concluded is

NSSI and Compulsive Disorders  93

higher than expected by chance (Snorrason et al., 2012). There is also considerable overlap in the symptom presentation and phenomenology of TTM and pathological skin-picking (Odlaug & Grant, 2008). Both TTM and skin-​picking involve recurrent, deliberate, and self-​inflicted behaviors that may involve rituals and tactile stimulation (Snorrason et  al., 2012). For instance, individuals with TTM may purposefully comb, stroke, or tug at a chosen hair prior to pulling it (Woods & Houghton, 2014). After the behavior, individuals may play with the hair between the fingers, inspect, bite or ingest it (Odlaug & Grant, 2008;Woods & Houghton, 2014). Similarly, individuals who skin-​pick may rub or touch the area of the skin prior to picking and afterward roll the picked skin between their fingers or ingest it (Snorrason et al., 2012). Such ritualized behaviors are often habitual, engrossing, and time-​consuming (Snorrason et al., 2012). In addition, neither NSSI nor TTM are preceded by pathological obsessions or concerns about potential harm (Flessner, Knopik, & McGeary, 2012; Woods et al., 2006) as commonly seen in OCD and BDD. The affective experiences surrounding the specific behaviors in TTM and NSSI are also similar (Snorrason et al., 2012; Zetterqvist, 2015). Individuals with TTM and NSSI may report an uncontrollable urge, mounting tension, or anxiety prior to hair-​pulling or self-​injuring (Whitlock et al., 2011; Woods et al., 2006). During and after hair-​pulling and skin-​picking, a majority of individuals experience temporary relief or gratification (Christenson et al., 1991; Snorrason et  al., 2012). Taken together, hair-​pulling and skin-​picking behaviors may be utilized to regulate negative emotions, or to a lesser extent, to enhance feelings of pleasure or satisfaction. Overall, preliminary review of the characteristics of TTM and NSSI, particularly skin-​picking, suggests that the behaviors may be related in phenomenology and function.

Hoarding Disorder A newly included diagnosis in the DSM-​5, HD is characterized by persistent unwillingness, inability, or difficulty discarding accumulated possessions, resulting in severely cluttered living spaces (APA, 2013). HD often leads to significant social, personal, and occupational consequences including eviction, familial discord, health code violations, or accidental fires (Frost, Steketee, & Tolin, 2011). No research to date has investigated the relationship between NSSI and HD and future research is warranted. However, the lack of a bodily component to HD suggests that the association with NSSI may not be significant.

Excoriation (Skin-​P icking) Disorder During the development of DSM-​5, two proposals for new disorders reflecting self-​injury were developed and field-​tested: NSSI disorder and skin-​picking disorder. Although NSSI disorder was not included as a clinical disorder in DSM-​ 5, SPD was accepted as a new diagnosis under the category of OCRDs (APA,

94  Justyna Jurska et al.

2013). The disorder was proposed and included as a diagnosis because of the prevalence of severe skin-​picking and co-​occurring psychopathology, distress, impairment, and injury associated with the behavior (e.g., Stein et  al., 2010), and the disorder’s performance on field trials (Lochner, Grant, Odlaug, & Stein, 2012). The hallmark of SPD is recurrent picking at the skin resulting in tissue damage, in addition to repeated attempts to stop or decrease the behavior and clinically significant distress or impairment (APA, 2013). Despite the inclusion of the SPD diagnosis into the DSM-5, use of the disorder is complicated in that skin-​picking is a commonly reported method of NSSI. Nearly 20% of U.S. adults who engage in NSSI report skin-​picking behavior, and 23% report interfering with wound healing (Klonsky, 2011). Among individuals seeking treatment for NSSI, over 50% reported skin-​picking as a method of NSSI (Andover, Schatten, Morris, Holman, & Miller, 2017). The DSM-​5 criteria for SPD specifically include NSSI as a differential consideration (APA, 2013), suggesting that skin-​picking in SPD cannot be performed to intentionally injure or cause pain. However, criteria for SPD may also apply to individuals who use skin-​picking as a method of NSSI. Guidance on discerning SPD from NSSI behaviors has focused on characteristics of the behaviors, such as the “chronic” nature of SPD and the “episodic” nature of NSSI (Snorrason, Stein, & Woods, 2013, p.  407), and frequent emphasis on rituals, thoughts, feelings related to skin imperfections in SPD as opposed to the use of NSSI to regulate negative emotions more generally (Stargell, Kress, Paylo, & Zins, 2016); however, differences between SPD and NSSI have not yet been researched. Consistent with the literature on NSSI, difficulties in emotion regulation have also been found among individuals who skin-​pick (Snorrason, Smári, & Ólafsson, 2010), and several studies have reported that skin-​picking decreases unwanted emotional states and may be performed to regulate emotions, in addition to being a source of pleasurable stimulation (e.g., Ameringen, Patterson, & Simpson, 2014; Tucker, Woods, Flessner, Franklin, & Franklin, 2011). Researchers note, however, that not all who skin-​pick do so to regulate emotional experiences (Jagger & Sterner, 2016), and skin-​picking can also be followed by an increase, rather than a decrease, in anxiety (Tucker et al., 2011). Further, research on pain perception among individuals with SPD suggests that, similar to NSSI, SPD is associated with decreased physiological response to a painful stimulus. In contrast to subjective reports of pain in NSSI, however, those with SPD did not subjectively report less pain than non-​pickers (Grant, Redden, & Chamberlain, 2017). Although criteria for SPD specifically rule out behaviors performed to intentionally harm oneself, the distinction may be unclear for individuals who engage in compulsive forms of NSSI. Further, support for the utility and necessity of conceptualizing skin-​picking as distinct from NSSI is limited, as this area has not been thoroughly investigated (Stein et al., 2010). Indeed, published studies of SPD often fail to note how and if NSSI was differentially assessed (e.g., Lochner et al., 2012; Odlaug et al., 2013). A body of research has developed to support the

NSSI and Compulsive Disorders  95

distinction between TTM and SPD (e.g., Snorrason et al., 2012), but this has not been replicated with NSSI. Some research suggests that severe forms of other BFRBs, such as severe nail-​biting, may be similar to NSSI in psychophysiological response to imagined episodes of the behavior, although NSSI may be more effective in reducing physiological arousal than severe nail-​biting (Wells, Haines,Williams, & Brain, 1999). Given the conceptualization of compulsive and impulsive forms of NSSI (Simeon & Favazza, 2001), additional research is necessary to determine how –​and if –​SPD differs from NSSI, thereby supporting its validity as a distinct disorder.

Treatment Response of OCRDs and NSSI Another approach to understanding the association between behaviors or disorders is to investigate similarities in treatment response, as responding to similar treatments may suggest similar underlying mechanisms of the behaviors. Overlap in treatment approaches is particularly common for habitual NSSI methods, TTM, and SPD due to their repetitive and body-​ focused nature (Woods, Flessner, & Conelea, 2008). In addition, there are similarities among the treatments for OCD, BDD, and NSSI. Therefore, we will focus on interventions used to treat OCRDs that have the greatest commonalities with NSSI, paying special attention to those that have also been used to treat NSSI, with an assumption that these treatments may affect similar underlying mechanisms between the conditions. To date, habit reversal training (HRT) is the most well supported treatment for individuals diagnosed with BFRBs, such as TTM and chronic skin-​picking (Bloch et al., 2007; Teng, Woods, & Twohig, 2006). HRT is based on behavioral principles and involves four primary components: awareness training (discriminating the occurrence of behavior and its antecedents), competing response training (introducing an antagonistic behavior that normalizes the response with a less noticeable/​harmful action), relaxation training, and social support (Azrin & Nunn, 1973; Piacentini & Chang, 2005). HRT has been found to reduce skin-​picking behaviors compared to a waitlist control (Teng et al., 2006) and is superior to pharmacological treatment for TTM (Bloch et  al., 2007). No studies to date have investigated the efficacy of HRT in treating individuals with NSSI. It is plausible that more compulsive methods of NSSI may also respond well to HRT treatment due to its focus on reinforcement contingencies and the emphasis on teaching patients alternative responses (Stanley, Fineran, & Brodsky, 2014). Cognitive behavioral therapy (CBT) may be a promising treatment for TTM (Ninan, Rothbaum, Marsteller, Knight, & Eccard, 2000). CBT for TTM incorporates awareness training and competing response training as found in HRT, as well as psychoeducation, centered on teaching patients about hair-​ pulling and self-​monitoring, and cognitive restructuring, focused on changing maladaptive thoughts around stressful circumstances and distinguishing between

96  Justyna Jurska et al.

minor setbacks and a relapse (Franklin & Tolin, 2007; van Minnen, Hoogduin, Keijsers, Hellenbrand, & Hendriks, 2003). CBT for TTM has been shown to be more effective at reducing hair pulling than medication, placebo, or a waitlist control condition (Ninan et al., 2000; van Minnen et al., 2003). Similarly, treatment of skin-​picking has largely focused on cognitive-​behavioral interventions (Grant et  al., 2012). Research has shown that even a four-​session CBT protocol is efficacious in reducing skin-​ picking (Schuck, Keijsers, & Rinck, 2011). In another study, self-​injurious skin-​picking substantially decreased among patients receiving interventions that coupled HRT techniques with psychoeducation and cognitive restructuring (Deckersbach et al., 2002). Researchers have also used CBT to treat NSSI (e.g., Muehlenkamp, 2006); such interventions incorporate monitoring to enhance the patient’s awareness of the self-​injurious behavior, improve mood tolerance, and replace maladaptive cognitions or coping skills with adaptive ones (Slee, Arensman, Garnefski, & Spinhoven, 2007). Acceptance and commitment therapy (ACT), which targets experiential avoidance (Hayes, Strosahl, & Wilson, 1999), assumes that individuals engage in pathological behavior, such as TTM (Snorrason, Berlin, & Lee, 2015) or NSSI, to avoid or escape aversive emotions, urges, or cognitive states. ACT has been combined with HRT to effectively treat TTM (Crosby, Dehlin, Mitchell, & Twohig, 2012; Woods, Wetterneck, & Flessner, 2006). Further, ACT alone or combined with behavior therapy has also been used to treat chronic skin-​picking (Flessner et al., 2008; Twohig, Hayes, & Masuda, 2006). However, research on ACT as a treatment for NSSI is limited. Dialectical behavior therapy (DBT) and DBT-​enhanced interventions can be effective in treating both TTM and NSSI. Initially developed to treat BPD, DBT focuses on helping patients manage emotional distress through interpersonal skills, mindfulness practice, and improved emotion regulation (Linehan, 1993). DBT has been shown to reduce NSSI in adults and adolescents across various study designs (e.g., Turner, Austin, & Chapman, 2014). The effectiveness of DBT in the treatment of NSSI is thought to be due to the intervention’s focus on reducing emotion dysregulation. DBT-​enhanced CBT has also been successfully used to treat TTM, although research has not investigated whether the observed symptom improvement was due specifically to the intervention’s focus on emotion regulation (Keuthen et al., 2012). Decoupling (DC), a novel self-​help intervention (Moritz & Rufer, 2011), can be considered a variant of HRT, as both treatments aim to actively interfere at the motor level to mitigate dysfunctional movements. However, unlike competing response training in HRT, which teaches individuals to perform an antagonist movement (e.g., clenching the fist as opposed to nail-​biting), DC aims to mimic the unwanted movement while changing its behavioral target.Therefore, the initial sequence of the new behavior must be identical to the unwanted behavior, but the subsequent concluding sequence should have a benign behavioral target. For example, an individual with TTM would start a hand movement towards their hair consistent with the old behavior, but then shift the concluding

NSSI and Compulsive Disorders  97

hand movement towards rubbing the ear instead (Moritz & Rufer, 2011). The entire behavioral sequence should be completed with an acceleration towards the end; this acceleration is theorized to make the new behavioral movement more salient and override the urge of the unwanted behavior (Moritz & Rufer, 2011). DC has been shown to be more effective than progressive muscle relaxation in the treatment of TTM (Moritz & Rufer, 2011) and nail-​biting (Moritz, Treszl, & Rufer, 2011). Only one study has investigated DC in the treatment of excessive skin-​picking (Moritz et al., 2012). Participants were randomized to receive self-​help manuals for either HRT or DC; those assigned to the self-​help HRT condition reported a greater reduction in skin-​picking than those in the self-​help DC condition. Given its success in treating TTM and nail-​biting, however, researchers suggest that clinician-​administered DC be investigated in the treatment of skin-​picking (Moritz et al., 2012). In reviewing the treatment literature for skin-​picking and other specific behaviors that are similar in form to NSSI, we can begin to compare how treatments for BFRBs are related to potential treatments for compulsive forms of NSSI. HRT, CBT, and DC place similar emphasis on behavioral techniques, which can be helpful for changing maladaptive, repetitive, and difficult-​to-​ control behaviors. The emphasis on cognitive and behavioral interventions for treating BFRBs is similar to suggestions for treating NSSI (Muehlenkamp, 2006).

Neurobiological and Neurochemical Associations Between OCRDs and NSSI OCD and some of the OCRDs are characterized by dysfunction of basal ganglia-​based circuits (Ferrão et al., 2009), while NSSI is better characterized by hyperarousal of the limbic system (Cullen et al., 2013) and enhanced amygdala and anterior cingulate cortex activation (Groschwitz & Plener, 2012; Plener, Bubalo, Fladung, Ludolph, & Lule, 2012), which may help to explain the poor emotion regulation associated with NSSI. Further, neuroimaging studies on cortisol levels and endogenous opioids point collectively to an insufficient stress response and altered pain perception that may be unique to NSSI (Groschwitz & Plener, 2012). While abnormalities in the serotonergic and dopaminergic neurotransmission have been fairly consistent in OCD and BDD, findings regarding serotonin and dopamine abnormalities have been inconsistent for NSSI, suggesting a need for future research (Stanley et  al., 2010). In addition, while treatment response of selective serotonin reuptake inhibitors (SSRIs) for NSSI, SPD, and TTM has shown mixed results (Bloch et al., 2007; Bloom & Holly, 2011), SSRIs and SRI (clomipramine) appear to be efficacious psychopharmacological treatments for OCD and BDD (Eddy, Dutra, Bradley, & Westen, 2004; Phillips & Hollander, 2008), suggesting a clearer role of serotonergic dysfunction in OCD and BDD. New lines of research on glutamatergic agents in treating individuals with NSSI and OCRDs are promising and likely to be utilized more with increased research (e.g., Chakrabarty, Bhattacharyya, Christopher, & Khanna, 2005; Cullen

98  Justyna Jurska et al.

et al., 2017). Further, opioid antagonists such as naltrexone have been shown to decrease NSSI (McGee, 1997; Symons,Thompson, & Rodriguez, 2004) and may also be promising in the treatment of compulsive behaviors with phenomenological similarity to NSSI (Grant et al., 2012).

Summary of OCRDs and NSSI Empirical research has begun to investigate the association between NSSI and disorders characterized by obsessive-​compulsive processes (McKay et  al., 2000), leading researchers to draw parallels between NSSI and specific OCRDs. Some OCRDs, such as TTM and SPD, are uniquely tied to NSSI by method and topography, with SPD behaviors often categorized as NSSI. As is true for NSSI, TTM and SPD are less likely to be triggered by obsessions, but rather have a tendency to coincide with negative emotional states. One of the key areas of overlap between OCRDs and NSSI is their affect regulation function and propensity to provide positive and negative reinforcement. In fact, both NSSI and BRFBs, several of which are OCRDs, are associated with deficits in emotion r­egulation, and the relief from negative affective states reinforces BFRBs (Roberts, O’Connor, & Bélanger, 2013).

Compulsive and Impulsive Subtypes of NSSI Several researchers have proposed further categorizing NSSI methods as compulsive or impulsive to better reflect the characteristics of these behaviors (Stein, Zohar, & Simeon, 2002; Simeon, Stein, & Hollander, 1995). Specifically, compulsive NSSI behaviors, including skin-​picking and other self-​injurious BFRBs, are habitual, repetitive (e.g., Favazza, 2012; Simeon et  al., 1995), and chronic (Wilhelm et al., 1999). The behaviors are experienced as unwanted and inconsistent with the individual and situation, and individuals often report attempts to resist the behavior (Simeon et al., 1995). Further, compulsive NSSI is negatively reinforced as it serves to decrease negative affect or tension (e.g., Simeon et al., 1995). Individuals with compulsive NSSI more often present for treatment at medical offices or dermatological practices than those with impulsive NSSI (Favazza, 2012). Impulsive NSSI behaviors, such as cutting, burning, and self-​ hitting, occur episodically and are often related to precipitating events. Like compulsive NSSI, impulsive NSSI behaviors are performed for affect regulation, but positive reinforcement is also reported, including gratification, pleasure, and sensation-​seeking (Simeon et al., 1995). Differences in self-​injurious behavior characteristics led to the conceptualization of impulsive and compulsive categories of NSSI, but research suggests a significant degree of overlap between impulsivity and compulsivity within the individual (Croyle & Waltz, 2007; Stein et al., 2002; Wilhelm et al., 1999). First, most individuals who engage in NSSI report multiple methods, often including both impulsive and compulsive NSSI methods. For example, nearly

NSSI and Compulsive Disorders  99

all participants in a nonclinical sample reporting impulsive NSSI behaviors also reported engaging in compulsive NSSI behaviors (Croyle & Waltz, 2007). Among individuals recruited specifically for severe skin-​picking, 16% reported that that they had cut themselves severely enough to require medical attention (Wilhelm et al., 1999). Although a proposed difference between impulsive and compulsive NSSI is the presence of positive reinforcement in impulsive NSSI, individuals who engage in compulsive NSSI may also report an increase in positive affect, such as satisfaction, after engaging in the behavior (Wilhelm et al., 1999). Further, assessments of constructs of impulsivity and compulsivity have suggested significant overlap within an individual. In one of the only studies to directly compare impulsive and compulsive NSSI behaviors, Croyle and Waltz (2007) found that although individuals who engaged in impulsive methods of NSSI reported more impulsivity than those who engaged in compulsive methods, the groups performed similarly on a measure of obsessive and compulsive behaviors, supporting an impulsivity–​compulsivity continuum rather than distinct classes of behaviors. Further complicating theory and research on impulsive and compulsive NSSI, behaviors can take on properties of the other type over time (Simeon et  al., 1995). For example, Stein and colleagues (2002) propose that impulsive NSSI behaviors may become more habitual over time and take on characteristics considered consistent with compulsive NSSI. The transition between impulsive and compulsive behavior may be explained by the reinforcement function of the behavior via decreased arousal associated with repetition of the act (Berlin & Hollander, 2008). Favazza (1996) found that the transition from episodic/​ impulsive to more chronic/​compulsive NSSI may occur after as few as five or as many as 20 episodes.That is, occasional or impulsive acts of NSSI may appear in adolescence and develop into a more chronic or repetitive pattern of NSSI over time (Nock, 2010). Conversely, progression from compulsive to impulsive NSSI methods was found in a sample of women (Black & Mildred, 2013). Even within skin-​picking, which is considered the quintessential compulsive NSSI behavior, researchers who first proposed diagnostic criteria for skin-​ picking disorder (psychogenic excoriation) proposed three subtypes of the behavior: compulsive, impulsive, and mixed (Arnold et al., 2001). According to this model, compulsive skin-​picking is reinforced through avoidance of increased negative affect or an aversive situation and may be performed in response to an obsession. Individuals who engage in compulsive skin-​picking do so with full awareness and with insight into the negative aspects of the behavior. Impulsive skin-​picking, however, is positively or negatively reinforced through a reduction or avoidance of negative affect. The behavior is performed more automatically, with little awareness, and with little insight into the behavior’s consequences. Arnold and colleagues (2001) suggest that an assessment of compulsive and impulsive features in skin-​picking may have implications in treatment selection and effectiveness, but this has not been investigated. However, increased levels of both impulsivity and obsessive-​compulsive symptoms were reported

100  Justyna Jurska et al.

by individuals with clinically significant skin-​picking compared to those with nonsignificant skin-​picking (Hayes et al., 2009), suggesting that both constructs may be experienced by people engaging in compulsive NSSI.

Summary and Implications Although relatively little research has investigated the association between NSSI and disorders characterized by compulsive behaviors, similarities in function, characteristics, treatment response, and neurobiology warrant further consideration. As reviewed in this chapter, research investigating the co-​occurrence of NSSI and OCRDs suggests a higher rate of overlap than expected by chance, and compulsive behaviors and NSSI can be phenotypically similar. Importantly, both NSSI and the compulsive behaviors in several OCRDs serve to regulate affect and are maintained by negative and even positive reinforcement. Further, researchers have suggested that NSSI behaviors themselves may be compulsive in nature. A review of this topic yields several noteworthy clinical and research implications. First, higher rates of co-​ occurrence than expected by chance suggest that clinicians should assess for both OCRDs and NSSI in their patients. This may be especially pertinent when working with patients with OCRDs, as NSSI is a known risk factor for suicide, and the identification of this behavior can inform the assessment of suicide risk. Further, as compulsive types of NSSI are often chronic and can result in serious medical complications such as lesions, infections, and disfigurement, they are worthy of clinical attention and intervention (Grant et al., 2012). Second, given the heterogeneity of NSSI methods and functions, some have suggested conceptualizing NSSI behaviors as impulsive or compulsive (Arnold et al., 2001; Simeon & Favazza, 2001). However, rather than reflecting a true dichotomy, research indicates that these behaviors are more likely to exist on a continuum, and the impulsive/​compulsive nature of NSSI behaviors may change over time. Although more research is needed to investigate the clinical usefulness and validity of differentiating NSSI by its impulsive or compulsive features, psychotherapeutic and psychopharmacological interventions for compulsive behaviors may be efficacious for compulsive NSSI. This has yet to be tested on a broader range of NSSI behaviors than skin-​picking and must be evaluated against empirically supported treatments for NSSI. Finally, of importance to both clinicians and researchers is the overlap between compulsive NSSI and the new DSM-​5 diagnosis of SPD. Historically, skin-​picking has been included as a method of NSSI, and the medical severity and the impact of the injuries on daily functioning substantiate its inclusion as a significant self-​injurious behavior. Although SPD includes a criterion stating that the skin-​picking must not be performed with an intention to self-​harm, the utility and use of this rule-​out remains to be evaluated. Further research is necessary to determine the validity and clinical utility of the SPD diagnosis separate from NSSI.

NSSI and Compulsive Disorders  101

In sum, research into the association between NSSI and compulsive disorders is in its infancy, but early data warrant additional examination to better address questions about their comorbidity, treatment response, and shared underlying mechanisms. In particular, further research is necessary to identify the overlap and distinctions between NSSI and SPD. Research on the associations among similar compulsive behaviors and NSSI generally, as well as compulsive NSSI specifically, may better our understanding of the mechanisms involved in NSSI and potentially aid in identifying more efficacious treatments for the behavior.

References American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington,VA: Author. Abramowitz, J. S., McKay, D., & Taylor, S. (2008). Obsessive-​compulsive disorder: Subtypes and spectrum conditions. Amsterdam: Elsevier. Abramowitz, J.  S., Taylor, S., & McKay, D. (2009). Obsessive-​compulsive disorder. The Lancet, 374, 491–​499. doi:10.1016/​S0140-​6736(09)60240–​3 Ameringen, M.  V., Patterson, B., & Simpson, W. (2014). DSM-​5 obsessive-​compulsive and related disorders: Clinical implications of new criteria. Depression and Anxiety, 31, 487–​493. doi:10.1002/​da.22259 Andover, M. S., Schatten, H. T., Morris, B. W., Holman, C. H., & Miller, I. W. (2017). An intervention for non-​suicidal self-​injury in young adults: A pilot randomized controlled trial. Journal of Consulting and Clinical Psychology, 85, 620–​631. doi:10.1037/​ ccp0000206 Arnold, L.  M., Auchenbach, M.  B., & McElroy, S.  L. (2001). Psychogenic excoriation: Clinical features, proposed diagnostic criteria, epidemiology and approaches to treatment. CNS Drugs, 15, 351–​359. Arnold, L. A., McElroy, S. L., Mutasim, D. F., Dwight, M. M., Lamerson, Cl. L., & Morris, E.  M. (1998). Characteristics of 34 adults with psychogenic excoriation. Journal of Clinical Psychiatry, 59, 509–​514. Azrin, N. H., & Nunn, R. G. (1973). Habit-​reversal: A method of eliminating nervous habits and tics. Behavior Research and Therapy, 11(4), 619–​628. Berlin, H. A., & Hollander, E. (2008). Understanding the difference between impulsivity and compulsivity. Psychiatric Times, 25, 58–​61. Black, E.  B., & Mildred, H. (2013). Predicting impulsive self-​injurious behavior in a sample of adult women. Journal of Nervous and Mental Disease, 201, 72–​75. doi:10.1097/​ NMD.0b013e31827ab1da Bloch, M.  H., Landeros-​Weisenberger, A., Dombrowski, P., Kelmendi, B., Wegner, R., Nudel, J., & … Coric, V. (2007). Systematic review:  Pharmacological and behavioral treatment for trichotillomania. Biological Psychiatry, 62, 839–​846. doi:10.1016/​ j.biopsych.2007.05.019 Bloom, C. M., & Holly, S. (2011). Toward new avenues in the treatment of non-​suicidal self-​injury. Journal of Pharmacy Practice, 2, 472–​477. doi:10.1177/​0897190011422877 Chakrabarty, K., Bhattacharyya, S., Christopher, R., & Khanna, S. (2005). Glutamatergic dysfunction in OCD. Neuropsychopharmacology, 30, 1735–​ 1740. doi:10.1038/​ sj.npp.1300733

102  Justyna Jurska et al. Christenson, G.  A., Mackenzie, T.  B., & Mitchell, J.  E. (1991). Characteristics of 60 adult chronic hair pullers. American Journal of Psychiatry, 148, 365–​370. doi:10.1176/​ ajp.148.3.365 Crosby, J.  M., Dehlin, J.  P., Mitchell, P.  R., & Twohig, M.  P. (2012). Acceptance and commitment therapy and habit reversal training for the treatment of trichotillomania. Cognitive and Behavioral Practice, 19(4), 595–​605. doi:10.1016/​j.cbpra.2012.02.002 Croyle, K. L., & Waltz, J. (2007). Subclinical self-​harm: Range of behaviors, extent, and associated characteristics. American Journal of Orthopsychiatry, 77, 332–​342. doi:10.1037/​ 0002-​9432.77.2.332 Cullen, B.  A., Samuels, J.  F., Bienvenu, O.  J., Grados, M., Hoehn-​Saric, R., Hahn, J., … Nestadt, G. (2001). The relationship of pathologic skin picking to obsessive-​ compulsive disorder. Journal of Nervous and Mental Disease, 189, 193–​195. doi:10.1097/​ 00005053-​200103000-​00010 Cullen, K.  R., Klimes-​Dougan, B., Westlund Schreiner, M., Carstedt, P., Marka, N., Nelson, K., … Eberly, L.E. (2018). N-​Acetylcysteine for non-​suicidal self-​injurious behavior in adolescents:  An open-​label pilot study. Journal of Child and Adolescent Psychopharmacology, 28(2), 136–​144. doi:10.1089/​cap.2017.0032 Cullen, K. R., Schreiner, M. W., Lariviere, L. L., & Klimes-​Dougan, B. (2013). An adolescent with non-​suicidal self-​injury: A case and discussion of neurobiological research on emotion regulation. American Journal of Psychiatry, 170, 828–​831. doi:10.1176/​appi. ajp.2013.12121598 Deckersbach, T., Wilhelm, S., Keuthen, N. J., Baer, L., & Jenike, M. A. (2002). Cognitive-​ behavior therapy for self-​injurious skin picking: A case series. Behavior Modification, 26, 361–​377. doi:10.1177/​0145445502026003004 du Toit, P. L., van Kradenburg, J., Niehaus, D. J., & Stein, D. J. (2001). Characteristics and phenomenology of hair-​pulling: An exploration of subtypes. Comprehensive Psychiatry, 42, 247–​256. doi:10.1053/​comp.2001.23134 Eddy, K. T., Dutra, L., Bradley, B., & Westen, D. (2004). A multidimensional meta-​analysis of psychotherapy and pharmacotherapy for obsessive-​compulsive disorder. Clinical Psychology Review, 24, 1011–​1030. doi:10.1016/​j.cpr.2004.08.004 Favazza, A. R. (1996). Bodies under siege: Self-​mutilation and body modification in culture and psychiatry. Baltimore, MD: Johns Hopkins University Press. Favazza, A.  R. (2012). Nonsuicidal self-​injury:  How categorization guides treatment. Current Psychiatry, 11, 21–​26. Ferrão, Y., Miguel, E., & Stein, D.  J. (2009). Tourette’s syndrome, trichotillomania, and obsessive-​compulsive disorder: How closely are they related? Psychiatry Research, 170, 32–​42. doi:10.1016/​j.psychres.2008.06.008 Flessner, C.  A., Knopik, V., & McGeary, J. (2012). Hair pulling disorder (Trichotillomania): Genes, neurobiology, and a model for understanding impulsivity and compulsivity. Psychiatry Research, 199, 151–​158. doi:10.1016/​j.psychres.2012.03.039. Flessner, C.  A., Woods, D.  W., Franklin, M.  E., Keuthen, N.  J., Piacentini, J., & Trichotillomania Learning Center Scientific Advisory Board. (2008). Styles of pulling in youths with trichotillomania: Exploring differences in symptoms severity, phenomenology, and comorbid psychiatric symptoms. Behavior Research and Therapy, 46, 1055–​ 1061. doi:10.1016/​j.brat.2008.06.006 Franklin, M.  E. & Tolin, D.  F. (2007). Treating trichotillomania:  Cognitive-​behavioral therapy for hairpulling and related problems. New  York, NY:  Springer Science + Business Media.

NSSI and Compulsive Disorders  103 Frost, R.  O., Steketee, G., & Tolin, D.  F. (2011). Comorbidity in hoarding disorder. Depression and Anxiety, 28, 876–​884. http://​doi.org/​10.1002/​da.20861 Garisch, J. A., & Wilson, M. S. (2015). Prevalence, correlates, and prospective predictors of non-​ suicidal self-​ injury among New Zealand adolescents:  Cross-​ sectional and longitudinal survey data. Child and Adolescent Psychiatry and Mental Health, 9, 1–​11. doi:10.1186/​s13034-​015-​0055-​6 Garrison, C. Z., Addy, C. L., McKeown, R. E., Cuffe, S. P., Jackson, K. L., & Waller, J. L. (1993). Nonsuicidal physically self-​damaging acts in adolescents. Journal of Child and Family Studies, 2, 339–​352. doi:1062-​1024/​93/​1200-​0339507.00/​ Glenn, C.  R., & Klonsky, E.  D. (2011). Prospective prediction of non-​suicidal self-​ injury: A longitudinal study in young adults. Behavior Therapy, 42, 751–​762. Grant, J. E., Mancebo, M. C., Pinto, A., Eisen, J. L., & Rasmussen, R. A. (2006). Impulse control disorders in adults with obsessive compulsive disorder. Journal of Psychiatric Research, 40, 494–​501. doi:10.1016/​j.jpsychires.2005.11.005 Grant, J.  E., Odlaug, B.  L., Chamberlain, S.  R., Keuthen, N.  J., Locher, C., & Stein, D. J. (2012). Skin picking disorder. The American Journal of Psychiatry, 169, 1143–​1149. doi:10.1176/​app.ajp.2012.12040508 Grant, J.  E., Redden, S.  A., & Chamberlain, S.  R. (2017). Cold pressor pain in skin picking disorder. Psychiatry Research, 249, 35–​38. doi:10.1016/​j.psychres.2016.12.050 Groschwitz, R., & Plener, P.  L. (2012). The neurobiology of non-​suicidal self-​injury (NSSI): A review. Suicidology Online, 3, 24–​32. Hasking, P. A., Heath, N. L., Kaess, M., Lewis, S. P., Pener, P. L., Walsh, B. W., … Wilson, M. S. (2016). Position paper for guiding response to non-​suicidal self-​injury in schools. School Psychology International, 37(6), 644–​663. Hayes, S. L., Storch, E. A., & Berlanga, L. (2009). Skin picking behaviors: An examination of the prevalence and severity in a community sample. Journal of Anxiety Disorders, 23, 314–​319. doi:10.1016/​j.janxdis.2009.01.008 Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (1999). Acceptance and commitment therapy: An experiential approach to behavior change. New York: Guilford Press. Hollander, E., Braun, A., & Simeon, D. (2008). Should OCD leave the anxiety disorders in DSM-​ V? The case for obsessive compulsive-​ related disorders. Depression and Anxiety, 25, 317–​329. doi:10.1002/​da.20500. Hollander, E., Friedberg, J. P., Wasserman, S.,Yeh, C-​C., Iyengar, R. (2005). The case for the OCD spectrum. In J. S. Abramowitz & A. C. Houts (Eds.), Concepts and controversies in obsessive-​compulsive disorder (pp. 95–​118). New York: Springer. Hollander, E., & Rosen, J. (2000). Obsessive-​compulsive spectrum disorders: A review. In M. Maj, N. Sartorius, A. Okasha, & J. Zohar (Eds.), Obsessive-​compulsive disorder (pp. 203–​224). Chichester: Wiley. Jacobson, C., & Luik, C.  C. (2014). Epidemiology and sociocultural aspects of non-​ suicidal self-​injury and eating disorders. In L. Claes & J. J. Muehlenkamp (Eds.), Non-​ suicidal self-​injury in eating disorders: Advancements in etiology and treatment (pp. 19–​34). Berlin: Springer-​Verlag. doi:10.1007/​978-​3-​642-​40107-​7 Jacobson, C. M., Muehlenkamp, J. J., Miller, A. L., & Turner, J. B. (2008). Psychiatric impairment among adolescents engaging in different types of deliberate self-​harm. Journal of Clinical Child and Adolescent Psychology, 37, 363–​375. doi:10.1080/​15374410801955771 Jagger, G. E., & Sterner,W. R. (2016). Excoriation: What counselors need to know about skin picking disorder. Journal of Mental Health Counseling, 38, 281–​297. doi:10.17744/​ mehc.38.4.01

104  Justyna Jurska et al. Keuthen, N.  J., O’Sullivan, R.  L., & Sprich-​Buckminster, S. (1998). Trichotillomania: Current issues in conceptualization and treatment. Psychotherapy and Psychosomatics, 67, 202–​213. doi:10.1159/​000012282 Keuthen, N.  J., Rothbaum, B.  O., Fama, J., Altenburger, E., Falkenstein, M.  J., Sprich, S.  E., … Welch, S.  S. (2012). DBT-​ enhanced cognitive-​ behavioral treatment for trichotillomania: A randomized controlled trial. Journal of Behavioral Addictions, 1, 106–​ 114. doi:10.1556/​JBA.1.2012.003 Klonsky, E. D. (2007). The functions of deliberate self-​injury: A review of the evidence. Clinical Psychology Review, 27, 226–​239. doi:10.1023/​B:JOBA.0000007455.08539.94 Klonsky, E.  D. (2009). The functions of self-​injury in young adults who cut themselves: Clarifying the evidence for affect regulation. Psychiatry Research, 166, 260–​268. doi:10.1016/​j.psychres.2008.02.008 Klonsky, E.D. (2011). Non-​ suicidal self-​ injury in United States adults:  Prevalence, sociodemographics, topography and functions. Psychological Medicine, 41, 1981–​1986. doi:10.1017/​S0033291710002497 Klonsky, E.  D., & Glenn, C.  R. (2009). Assessing the functions of non-​suicidal self-​ injury:  Psychometric properties of the inventory of statements about self-​ injury (ISAS). Journal of Psychopathology and Behavioral Assessment, 31, 215–​219. doi:10.1007/​ s10862-​008-​9107-​z Klonsky, E.  D., Muehlenkamp, J.  J., Lewis, S.  P., & Walsh, B. (2011). Nonsuicidal self-​ injury: Advances in psychotherapy-​evidence-​based practice. Cambridge, MA: Hogrefe. Linehan, M. (1993). Cognitive-​ behavioral treatment of borderline personality disorder. New York: Guilford Press. Lochner, C., Grant, J. E., Odlaug, B. L., & Stein, D. J. (2012). DSM-​5 field survey: Skin picking disorder. Annals of Clinical Psychiatry, 24, 300–​304. doi:10.1002/​da.22011 McGee, M. D. (1997). Cessation of self-​mutilation in a patient with borderline personality disorder treated with naltrexone. The Journal of Clinical Psychiatry, 58, 32–​33. McKay, D., & Andover, M.  S. (2012). Should non-​suicidal self-​injury be a putative obsessive-​compulsive related condition? A critical appraisal. Behavior Modification, 36, 3–​17. doi:10.1177/​0145445511417707 McKay, D., Kulchycky, S., & Danyko, S. (2000). Borderline personality and obsessive-​ compulsive symptoms. Journal of Personality Disorders, 14, 57–​ 63. doi:10.1521/​ pedi.2000.14.1.57 Moritz, S., Fricke, S., Treszl, A., & Wittekind, C.  E. (2012). Do it yourself! Evaluation of self-​help habit reversal training versus decoupling in pathological skin picking: A pilot study. Journal of Obsessive-​Compulsive and Related Disorders, 1, 41–​47. doi:10.1016/​ j.jocrd.2011.11.001 Moritz, S., & Rufer, M. (2011). Movement decoupling: A self-​help intervention for the treatment of trichotillomania. Journal of Behavior Therapy and Experimental Psychiatry, 42, 74–​80. doi:10.1016/​j.jbtep.2010.07.001 Moritz, S., Treszl, A., & Rufer, M. (2011). A randomized controlled trial of a novel self-​help technique for impulse control disorders:  A study on nail-​biting. Behavior Modification, 35, 468–​485. doi:10.1177/​0145445511409395 Muehlenkamp, J.  J. (2006). Empirically supported treatments and general therapy guidelines for non-​suicidal self-​injury. Journal of Mental Health Counseling, 28, 166–​185. doi:10.17744/​mehc.28.2.6w61cut2lxjdg3m7 Mufaddel, A., Osman, O. T., Almugaddam, F., & Jafferany, M. (2013). A review of body dysmorphic disorder and its presentation in different clinical settings. The Primary Care Companion for CNS Disorders, 15, doi:10.4088/​PCC.12r01464

NSSI and Compulsive Disorders  105 Najmi, S., Kuckertz, J.  M., & Amir, N. (2010). Automatic avoidance tendencies in ­ individuals with contamination-​ related obsessive-​ compulsive symptoms. Behavior Research and Therapy, 48, 1058–​1062. http://​doi.org/​10.1016/​j.brat.2010.06.007 Najmi, S., Wegner, D.M., & Nock, M.K. (2007). Thought suppression and self-​injurious thoughts and behaviors. Behavior Research and Therapy, 45, 1957–​1965. Nestadt, G., Samuels, J., Riddle, M. A., Liang, K.Y., Bienvenu, O. J., Hoehn-​Saric, R., Grados, M., & Cullen, B. (2001). The relationship between obsessive compulsive disorder and anxiety and affective disorders:  Results from the Johns Hopkins OCD Family Study. Psychological Medicine, 31, 481–​487. doi:10.1017/​S0033291701003579 Ninan, P. T., Rothbaum, B. O., Marsteller, F. A., Knight, B. T., & Eccard, M. B. (2000). A placebo-​ controlled trial of cognitive-​ behavioral therapy and clomipramine in trichotillomania. Journal of Clinical Psychiatry, 61, 47–​50. doi:10.4088/​JCP.v61n0111 Nitkowski, D., & Petermann, F. (2011). Non-​suicidal self-​injury and comorbid mental disorders:  a review. Fortschritte der Neurologie-​ Psychiatrie, 79, 9–​ 20. doi:10.1055/​ s-​0029-​1245772 Nixon, M. K., Cloutier, P. F., & Aggarwal, S. (2002). Affect regulation and addictive aspects of repetitive self-​injury in hospitalized adolescents. Journal of the American Academy of Child & Adolescent Psychiatry, 41(11), 1333–​1341. doi:10.1097/​00004583-​200211000-​00015 Nock, M.  K. (2010). Self-​ injury. Annual Review of Clinical Psychology, 6, 339–​ 363. doi:10.1146/​annurev.clinpsy.121208.131258 Nock, M.  K., Joiner, T.  E., Gordon, K.  H., Lloyd-​Richardson, E., & Prinstein, M.  J. (2006). Non-​suicidal self-​injury among adolescents: Diagnostic correlates and relation to suicide attempts. Psychiatry Research, 144, 65–​72. doi:10.1016/​j.psychres.2006.05.010 Nock, M.  K., & Prinstein, M. (2004). A functional approach to the assessment of self-​mutilative behavior. Journal of Counseling and Clinical Psychology, 72, 885–​890. doi:0.1037/​0022-​006X.72.5.885 Odlaug, B.  L., & Grant, J.  E. (2008). Trichotillomania and pathological skin picking: Clinical comparison with an examination of comorbidity. Annals of Clinical Psychiatry, 20, 57–​63. doi:10.1080/​10401230802017027 Odlaug, B.  L., Lust, K., Schriber, L.  R.  N., Christenson, G., Derbyshire, K., & Grant, J.  E. (2013). Skin picking disorder in university students:  Health correlates and gender differences. General Hospital Psychiatry, 35, 168–​ 173. doi:10.1016/​ j.genhosppsych.2012.08.006 Phillips, K. A., & Hollander, E. (2008). Treating body dysmorphic disorder with medication:  Evidence misconceptions, and a suggested approach. Body Image, 5, 13–​27. doi:10.1016/​j.bodyim.2007.12.003 Phillips, K. A., & Kaye, W. H. (2007). The relationship of body dysmorphic disorder and eating disorder to obsessive-​compulsive disorder. CNS Spectrums, 12, 347–​358. Phillips, K. A., Menard, W., Fay, C., & Weinberg, R. (2005). Demographic characteristics, phenomenology, comorbidity, and family history of 200 individuals with body dysmorphic disorder. Psychosomatics, 46, 317–325. doi:10.1176/appi.psy.46.4.317 Phillips, K. A., & Taub, S. L. (1995). Skin picking as a symptom of body dysmorphic disorder. Psychopharmacology Bulletin, 31, 279–​288. Piacentini, J., & Chang, S. (2005). Habit reversal training for tic disorders in children and adolescents. Behavior Modification, 29, 803–​822. doi:10.1177/​0145445505279385 Plener, P.  L., Bubalo, N., Fladung, A.  K., Ludolph, A.  G., & Lule, D. (2012). Prone to excitement:  Adolescent females with non-​suicidal self-​injury (NSSI) show altered cortical pattern to emotional and NSS-​related material. Psychiatry Research, 203, 146–​ 52. doi:10.1016/​j.pscychresns.2011.12.012

106  Justyna Jurska et al. Roberts, S., O’Connor, K., & Belanger, C. (2013). Emotion regulation and other ­psychological models for body-​focused repetitive behaviors. Clinical Psychology Review, 33, 745–​762. doi:10.1016/​j.cpr.2013.05.004 Schuck, K., Keijsers, G., & Rinck, M. (2011). The effects of brief cognitive-​behavior therapy for pathological skin picking: A randomized comparison to wait-​list control. Behavior Research and Therapy, 49, 11–​17. doi:10.1016/​j.brat.2010.09.005 Selby, E.  A., Nock, M.  A., & Kranzler, A. (2014). How does self-​ injury feel? Examining automatic positive reinforcement in adolescent self-​injurers with experience sampling. Psychiatry Research, 215, 417–​423. doi:10.1016/​j.psychres.2013.12.005 Semiz, U., Basoglu, C., Cetin, M., Ebrinc, S., Uzun, O., & Ergun, B. (2008). Body dysmorphic disorder in patients with borderline personality disorder:  Prevalence, clinical characteristics, and role of childhood trauma. Acta Neuropsychiatrica, 20, 33–​40. doi:10.1111/​j.1601-​5215.2007.00231.x Simeon, D., & Favazza, A.  R. (2001). Self-​injurious behaviors:  Phenomenology and assessment. In D. Simeon & E. Hollandar (Eds.), Self-​injurious behaviors: Assessment and treatment (pp. 1–​28). Washington, DC: American Psychiatric Publishing, Inc. Simeon, D., Stein, D.  J., & Hollander, E. (1995). Depersonalization disorder and self-​ injurious behavior. Journal of Clinical Psychiatry, 56, 36–​39. Slee, N., Arensman, E., Garnefski, N., & Spinhoven, P. (2007). Cognitive-​behavioral therapy for deliberate self-​harm. Crisis, 28, 175–​182. doi:10.1027/​0227-​5910.28.4.175 Snorrason, I., Belleau, E. L., & Woods, D. W. (2012). How related are hair pulling disorder (trichotillomania) and skin picking disorder? A review of evidence for comorbidity, similarities, and shared etiology. Clinical Psychology Review, 32, 618–​629. doi:10.1016/​ j.cpr.2012.05.008 Snorrason, I., Berlin, G.  S., & Lee, H. (2015). Optimizing psychological interventions for  trichotillomania disorder):  An update on current empirical status. Psychology Research and Behavior Management, 8, 105–​113. doi:10.2147/​PRBM.S53977 Snorrason, I., Smári, J., & Ólafsson, R. P. (2010). Emotion regulation in pathological skin picking: Findings from a non-​treatment seeking sample. Journal of Behavior Therapy and Experimental Psychiatry, 41, 238–​245. doi:10.1016/​j.jbtep.2010.01.009 Snorrason, I., Stein, D.  J., & Woods, D.  W. (2013). Classification of excoriation (skin picking) disorder: Current status and future directions. Acta Psychiatrica Scandinavica, 128, 406–​407. doi:10.111/​acps.12153 Soriano, J. L., O’Sullivan, R. L., Baer, L., Phillips, K. A., McNally, R. J., & Jenike, M. A. (1996). Trichotillomania and self-​esteem: A survey of 62 female hair pullers. Journal of Clinical Psychiatry, 57, 77–​82. Stanley, B., Fineran, V., & Brodsky, B. (2014). Psychological treatments for non-​suicidal self-​injury. In M. K. Nock (Ed.), The Oxford handbook of suicide and self-​injury (pp. 409–​ 418). New York: Oxford University Press. Stanley, B., Sher, L., Wilson, S., Ekman, R., Huang, Y., & Mann, J. J. (2010). Nonsuicidal self-​ injurious behavior, endogenous opioids, and monoamine neurotransmitters. Journal of Affect Disorders, 124, 134–​140. doi:10.1016/​j.jad.2009.10.028 Stargell, N. A., Kress, V. E., Paylo, M. J., & Zins, A. (2016). Excoriation disorder: Assess­ ment, diagnosis and treatment. The Professional Counselor, 6, 50–​60. doi:10.15241/​ nas.6.1.50 Stein, D. J., Fineberg, N. A., & Reghunandanan, S. (2015). Obsessive-​compulsive and related disorders. Oxford: Oxford University Press.

NSSI and Compulsive Disorders  107 Stein, D.  J., Grant, J.  E., Franklin, M.  E., Keuthen, N., Lochner, C., Singer, H.  S., & Woods, D. W. (2010). Trichotillomania (hair pulling disorder), skin picking disorder, and stereotypic movement disorder: Toward DSM-​V. Depression and Anxiety, 27, 611–​ 626. doi:0.1002/​da.20700 Stein, D. J., Zohar, J., & Simeon, D. (2002). Compulsive and impulsive aspects of self-​ injurious behavior. In K.L. Davis, C. Nemeroff, J. Coyle, & D. Charney (Eds.), Psychopharmacology: The fifth generation of progress. Philadelphia, PA: Lippincott,Williams, & Wilkins. Symons, F.  J., Thompson, A., & Rodriguez, M.  C. (2004). Self-​injurious behavior and the efficacy of naltrexone treatment: A quantitative synthesis. Developmental Disabilities Research Reviews, 10, 193–​200. doi:10.1002/​mrdd.20031 Teng, E. J.,Woods, D. W., & Twohig, M. P. (2006). Habit reversal as a treatment for chronic skin picking:  A pilot investigation. Behavior Modification, 30, 411–​422. doi:10.1177/​ 0145445504265707 Tucker, B. T.,Woods, D. W., Flessner, C. A., Franklin, S. A., & Franklin, M. E. (2011).The skin picking impact project: Phenomenology, interference, and treatment utilization of pathological skin picking in a population-​based sample. Journal of Anxiety Disorders, 25, 88–​95. doi:10.1016/​j.janxdis.2010.08.007 Turner, B. J., Austin, S. B., & Chapman, A. L. (2014). Treating nonsuicidal self-​injury: A systematic review of psychological and pharmacological interventions. The Canadian Journal of Psychiatry, 59, 576–​585. doi:10.1177/​070674371405901103 Twohig, M., Hayes, S., & Masuda, A. (2006). A preliminary investigation of acceptance and commitment therapy as a treatment for chronic skin picking. Behavior Research and Therapy, 44, 1513–​1522. doi:10.1016/​j.brat.2005.10.002 van Minnen, A., Hoogduin, K.  L., Keijsers, G.  J., Hellenbrand, I., & Hendriks, G. (2003).  Treatment of trichotillomania with behavioral therapy or fluoxetine:  A randomized, waiting-​list controlled study. Archives of General Psychiatry, 60, 517–​522. doi:10.1001/​archpsyc.60.5.517 Veale, D. (2001). Cognitive-​behavioral therapy for body dysmorphic disorder. Advances in Psychiatric Treatment, 7, 125–​132. Veale, D., & Gilbert, P. (2014). Body dysmorphic disorder:  The functional and evolutionary context in phenomenology and a compassionate mind. Journal of Obsessive-​ Compulsive and Related Disorders, 3, 150–​160. doi:10.1016/​j.jocrd.2013.11.005 Washburn, J. J., Gebhardt, M., Styer, D. M., Juzwin, K. R., & Gottlieb, L. (2012). Co-​ occurring disorders in the treatment of non-​suicidal self-​injury: An evidence-​informed approach. Journal of Cognitive Psychotherapy:  An International Quarterly, 26, 348–​364. doi:10.1891/​0889-​8391.26.4.348 Washburn, J. J., Juzwin, K. R., Styer, D. M., & Aldridge, D. (2010). Measuring the urge to self-​injure: Preliminary data from a clinical sample. Psychiatry Research, 178(3), 540–​ 544. doi:10.1016/​j.psychres.2010.05.018 Wells, J. H., Haines, J.,Williams, C. L., & Brain, K. L. (1999).The self-​mutilative nature of severe onychophagia: A comparison with self-​cutting. Canadian Journal of Psychiatry, 44, 40–​47. doi:10.1177/​070674379904400105 Whitlock, J., Muehlenkamp, J., Purington, A., Eckenrode, J., Barreira, P., Baral Abrams, G., … Knox, K. (2011). Nonsuicidal self-​injury in a college population: General trends and sex differences. Journal of American College Health, 59, 691–​698. doi:10.1080/​ 07448481.2010.529626

108  Justyna Jurska et al. Wilhelm, S., Keuthen, N.  J., Deckersbach, T., Engelhard, I.  M., Forker, A.  E., Baer, L. … & Jenike, M.  A. (1999). Self-​injurious skin picking:  Clinical characteristics and comorbidity. Journal of Clinical Psychiatry, 60, 454–​459. Woods, D., Flessner, C., & Conelea, C. (2008). Habit disorders. In M. Hersen (Series Ed.) & D. Reitman (Vol. Ed.), Handbook of psychological assessment, case conceptualization, and treatment: Vol 7. Children and adolescents (pp. 542–​570). New York: Wiley. Woods, D., Flessner, C., Franklin, M., Keuthen, N., Goodwin, R., Stein, D. J., Walther, M. & the Trichotillomania Learning Center Scientific Advisory Board. (2006). The trichotillomania impact project (TIP): Exploring phenomenology, functional impairment, and treatment utilization. Journal of Clinical Psychiatry, 67, 1877–​1888. Woods, D.  W., & Houghton, D.  C. (2014). Diagnosis, evaluation, and management of trichotillomania. The Psychiatric Clinics of North America, 37, 301–​317. doi:10.1016/​ j.psc.2014.05.005. Woods, D. W., Wetterneck, C. T., & Flessner, C. A. (2006). A controlled evaluation of acceptance and commitment therapy plus habit reversal for trichotillomania. Behavior Research and Therapy, 44, 639–​656. doi:10.1016/​j.brat.2005.05.006 Zetterqvist, M. (2015). The DSM-​5 diagnosis of non-​suicidal self-​injury disorder:  A review of the empirical literature. Child and Adolescent Psychiatry and Mental Health, 9, 1–​13. doi:10.1186/​s13034-​015-​0062-​7

Chapter 7

Nonsuicidal and Suicidal Self-​I njury Bita Zareian and E. David Klonsky

Introduction NSSI was recognized as a potentially distinct and important behavioral phenomenon as early as 1938. In his book, Man Against Himself, Karl Menninger proposed that patients engage in NSSI to avoid attempting suicide, and in contrast to a suicide attempt, the intention behind NSSI is not to die (Menninger, 1938). Nonetheless, the relationship and distinctions between NSSI and suicide has been the source of considerable controversy over the decades since. Since 1980, the Diagnostic and Statistical Manual of Mental Disorders (APA, 1980, 1987, 1994, 2013) has combined NSSI and suicidal behavior into a single criterion for borderline personality disorder, suggesting that NSSI and suicidality lack important distinctions. The conflating of NSSI and suicidal behavior can also be seen in the terminology used to refer to the behaviors. Terms such as parasuicide and deliberate self-​harm have sometimes been utilized to refer to NSSI specifically, and other times to refer to both NSSI and suicidal self-​injury. As a result, many clinicians and researchers did not differentiate between NSSI and suicide attempts in their practice or research (Isometsä & Lönnqvist, 1998; Ogundipe, 1999). Despite problems with conflating NSSI and suicide attempts (O’Carroll et  al., 1996), some researchers have explicitly argued that NSSI and suicide attempts are not meaningfully distinct and do not require separate assessments in research studies (Hawton, Rodham, Evans, & Weatherall, 2002; Kapur, Cooper, O’Connor, & Hawton, 2013). The onset of the twenty-​first century was a turning point for NSSI research. First, it became almost universally accepted that NSSI represents a distinct clinical phenomenon that should not be conflated with suicide or borderline personality disorder. For example, DSM-​5 includes draft criteria for an independent NSSI diagnostic entity (APA, 2013). Moreover, authoritative and highly cited clinical and scientific sources now routinely distinguish NSSI from suicide (e.g., Klonsky, 2007; Muehlenkamp, 2005; Nock, 2010). In addition, there has been a much-​needed proliferation of measures specifically developed to assess NSSI as an entity separate from suicidal attempts. These include the Self-​Injurious Thoughts and Behaviors Interview (Nock et al., 2007), Deliberate Self-​Harm Inventory (Gratz, 2001), Alexian Brothers Assessment of Self-​Injury (Washburn

110  Bita Zareian and E. David Klonsky

et  al., 2015), Inventory of Statements About Self-​injury (Klonsky & Glenn, 2009), and Nonsuicidal Self-​Injury Disorder Scale (Victor, Davis, & Klonsky, 2017). As a direct result of improved definitions and measurement, knowledge of NSSI has increased exponentially over the past 10–​20 years. We now have the information to articulate the ways in which NSSI and suicide attempts overlap and differ. The present chapter describes this relationship. First, we review the research on differences between NSSI and suicide attempts. Second, we describe the empirical overlap between NSSI and suicide attempts, as well as the theoretical perspectives to explain this overlap. Finally, we address the characteristics of NSSI and self-​injurers that appear to best predict suicide attempt history and suicide risk.

Distinctions between NSSI and Suicide Attempts NSSI differs from suicide attempts in several ways including function, method, frequency, and prevalence. Even though nonsuicidal and suicidal acts can have similar functions, such as to “stop aversive feelings” (Brown, Comtois, & Linehan, 2002; Tapola, Wahlström, Kuittinen, & Lappalainen, 2015), their functions differ in at least one basic respect: in contrast to suicide, NSSI lacks an intention to die (Nock, 2010; Tapola et al., 2015), and most individuals who engage in NSSI do not believe that their injuries will result in death (Patton et  al., 1997). In line with these findings, those who engage in NSSI can be differentiated from those who have a history of suicide attempt by their attitude towards life  –​ NSSI subjects show less repulsion to life than subjects with a history of suicide attempt (Muehlenkamp & Gutierrez, 2004). Additionally, among people with NSSI, those with a history of suicide attempt have less attraction to life in comparison to those without a history of suicide attempt (Whitlock & Knox, 2007). Moreover, some patients engage in NSSI to escape suicidal thoughts and to avoid attempting suicide (Klonsky, 2007; Orlando, Broman-​Fulks, Whitlock, Curtin, & Michael, 2015; Paul, Tsypes, Eidlitz, Ernhout, & Whitlock, 2015; Rodav, Levy, & Hamdan, 2014). For instance, a somewhat common reason for NSSI reported in a sample of patients with borderline personality disorder was “to prevent me from acting on suicidal feelings” (Shearer, 1994). Likewise, 41% of self-​injurers in a nonclinical adolescent sample and 48% of self-​injurers in an inpatient adolescent sample endorsed similar anti-​suicide reasons for self-​injury (Laye-​Gindhu & Schonert-​Reichl, 2005; Nixon, Cloutier, & Aggarwal, 2002). It is important to note, however, that the majority of those who self-​injure report never having felt suicidal while engaging in NSSI (Klonsky, 2011). NSSI and suicide attempts can be further differentiated by the types of method, variety of methods, and lethality of methods used by individuals who engage in these behaviors. NSSI usually includes nonlethal methods which do not need medical attention (Muehlenkamp & Gutierrez, 2007), whereas suicide attempts usually involve more lethal means and often require medical attention

Nonsuicidal and Suicidal Self-Injury  111

(Mars et al., 2014; Muehlenkamp, 2005; Tapola et al., 2015). For example, while NSSI commonly includes nonlethal methods such as shallow cutting, scratching, burning, and hitting oneself (Saraff & Pepper, 2014), more lethal methods, such as poisoning and hanging, are almost exclusively used for suicide attempts but not NSSI (Mars et al., 2014; Tapola et al., 2015). Suicide attempts and NSSI also differ in terms of the variety of methods utilized. Individuals who engage in NSSI usually use multiple methods of self-​ injury, whereas those who attempt suicide usually have one method of choice (Muehlenkamp, 2005; Muehlenkamp & Gutierrez, 2007). Between 20% and 93% of those who engage in NSSI use more than one method, in comparison to only 6–​10% of those who have a history of suicide attempt (Kim et al., 2015; Muehlenkamp & Gutierrez, 2007; Saraff & Pepper, 2014). Similarly, Groschwitz et  al. (2015) found a significant difference between the number of methods used for NSSI (M = 3.9) and the number of methods used for suicide attempt (M = 1.3). Another difference between NSSI and suicide attempts is the frequency by which these behaviors occur. Suicide attempts happen less frequently than NSSI, a pattern observed in both clinical and nonclinical samples (Hamza, Stewart, & Willoughby, 2012). In a community sample of adolescents, most participants who had a history of NSSI reported two to three incidents of self-​injury, whereas most who had a history of suicide attempts reported just one attempt (Muehlenkamp & Gutierrez, 2007). The difference is even more pronounced in clinical samples. In a sample drawn from inpatient adolescents who reported NSSI in past 12 months, the average number of lifetime suicide attempts was 2.8, whereas the average number of NSSI behaviors in the past year was more than 100 (Nock, Joiner, Gordon, Lloyd-​Richardson, & Prinstein, 2006). Likewise, in another sample of adolescent inpatients, the average number of NSSI behaviors and suicide attempts were, respectively, 101.3 vs. 3.1 (Groschwitz et al., 2015). A sample of adult inpatients showed a similar pattern: number of lifetime suicide attempts averaged 2.1 whereas number of lifetime NSSI instances averaged 156.9 (Andover & Gibb, 2010). A final difference between NSSI and suicide attempt is their prevalence. Lifetime prevalence of suicide attempts in community samples of both adults and adolescents is between 5% and 9% (Mars et  al., 2014; Muehlenkamp & Gutierrez, 2007; Nock & Kessler, 2006), whereas lifetime rates of NSSI among adolescents and young adults is between 13% and 21% (Baetens, Claes, Muehlenkamp, Grietens, & Onghena, 2011; Brausch & Gutierrez, 2009; Ross & Heath, 2002).

Co-​O ccurrence of NSSI and Suicide Attempts Even though NSSI and suicide are different from each other on many dimensions, they co-​occur frequently (Hamza et al., 2012). Among community samples of adolescents and young adults, NSSI is a strong predictor of suicidality

112  Bita Zareian and E. David Klonsky

(Cheung et al., 2013; Garrison et al., 1993; Tang et al., 2011; Whitlock & Knox, 2007; Whitlock, Muehlenkamp, & Eckenrode, 2008). For instance, in samples of college students, NSSI was associated with higher suicide ideation, suicide plans, suicide attempts, and frequency of suicide attempt, both in the past 12 months and lifetime time frames (Glenn & Klonsky, 2009; Martin, Swannell, Hazell, Harrison, & Taylor, 2010). Similarly, in samples of high school students, those who engaged in NSSI were more likely to have suicide ideation and suicide plans, and they were more likely to have a history of suicide attempts, including multiple suicide attempts (Brunner et  al., 2007; Laye-​Gindhu & Schonert-​Reichl, 2005; Lloyd-​Richardson, Perrine, Dierker, & Kelley, 2007). Clinical samples of inpatients and outpatients show a similar pattern (Claes et  al., 2010; Zlotnick, Donaldson, Spirito, & Pearlstein, 1997). For instance, in a sample of adult inpatients, NSSI was significantly correlated with history of suicide attempt and number of lifetime suicide attempts (Andover & Gibb, 2010). Likewise, in samples of outpatient adolescents, suicide attempts were more prevalent among those who engaged in NSSI than those who did not (Favaro et al., 2008; Schwartz, Cohen, Hoffmann, & Meeks, 1989). Importantly, the relationship between NSSI and suicidality persists even when demographic factors (Garrison et al., 1993) and clinical variables (e.g., depression, borderline personality disorder, hopelessness) are controlled (Andover & Gibb, 2010). In fact, NSSI seems to be a better predictor of suicide attempt history than commonly cited risk factors such as depression and borderline personality disorder (Klonsky, May, & Glenn, 2013). Notably, while the pattern described above is based on cross-​sectional data, the strong association of NSSI and attempted suicide is supported by several longitudinal studies. In a study assessing suicide ideation and attempt in inpatient adolescents, NSSI was associated not only with higher baseline suicide ideation but with a lower remission rate in suicidal ideation during a follow up period (Prinstein et al., 2008). Similarly, in a sample of university students, NSSI was associated with higher suicide ideation at one-​year follow-​up (Hamza & Willoughby, 2014). Perhaps most surprisingly, in two randomized control trials assessing the efficacy of different treatments for depressed adolescents, NSSI was the best predictor of suicide attempt at 6 and 7 months follow-​up –​an association that remained robust even when controlling for suicide attempt history (Asarnow et al., 2011; Wilkinson, Kelvin, Roberts, Dubicka, & Goodyer, 2011). Interestingly, the reverse relationship was not found; that is, history of suicide attempts at baseline did not predict NSSI at follow-​up in either of these two studies, suggesting that the value of NSSI in predicting future suicide attempt is higher than the value of past suicide attempts in predicting future NSSI (Hamza et al., 2012). Longitudinal studies in community samples of adolescents demonstrated similar results: after controlling for variables such as depression and history of suicide attempt, NSSI was associated with both suicide ideation and suicide attempt at follow-​up (Guan, Fox, & Prinstein, 2012). Similarly, in a sample of

Nonsuicidal and Suicidal Self-Injury  113

college students followed for three years, those who had engaged in five or more incidents of NSSI were four times more likely to have either suicidal thoughts or behaviors, and 3.4 times more likely to have suicidal behaviors, in comparison to those with no history of NSSI. This pattern remained even after controlling for covariates such as demographic variables, psychosocial variables, history of mental health illness, and history of being treated for mental illness (Whitlock et al., 2013). Relatedly, after following a sample of high school students for a year,You and Lin (2015) found that NSSI predicted suicide attempt at follow-​up above and beyond suicidal ideation.

Understanding the NSSI–​S uicide Relationship Several potential theoretical perspectives have been utilized to explain the relationship between NSSI and suicidality. We summarize these below. Third Variables One theory about the association of NSSI and suicidal behaviors is that these two variables are correlated because they are both associated with a “third variable,” such as depression, hopelessness, biological factors (e.g., serotonergic system dysfunction), or other psychobiological factors that may be common to both NSSI and suicide (Hamza et al., 2012). There is some evidence supporting third variable perspectives. For instance, both NSSI and suicide attempts are associated with borderline personality disorder, histories of sexual and emotional abuse (Whitlock & Knox, 2007), as well as impulsivity, depression, hopelessness, and suicidal ideation (Andover & Gibb, 2010; Claes et al., 2010; Muehlenkamp, Ertelt, Miller, & Claes, 2011; Taliaferro & Muehlenkamp, 2015). Thus, the presence of one or more of these variables can increase risk for both NSSI and suicidal behavior, and thereby cause the two behaviors to co-​occur. Although many potential third variables are associated with both NSSI and suicidal behaviors, there is a serious shortcoming to this explanation:  if the third variable theory is correct, controlling for third variables should render the association between NSSI and suicidal behaviors nonsignificant (Hamza et  al., 2012). When variables such as hopelessness, depression, borderline personality disorder, anxiety, and impulsivity are controlled for, however, the association between NSSI and suicide remains significant (Andover & Gibb, 2010; Klonsky et  al., 2013). Furthermore, as noted earlier in this chapter, the association of NSSI with suicide attempts is stronger than those of the variables mentioned above (Klonsky et al., 2013). Moreover, the association of NSSI to suicide attempts remains robust even when covariates are included in longitudinal studies (Asarnow et al., 2011; Wilkinson, Kelvin, Roberts, Dubicka, & Goodyer, 2011). Taken together, findings suggest that while third variables may account for some of the association between NSSI and suicide attempts, they

114  Bita Zareian and E. David Klonsky

cannot fully explain this relationship. Instead, there appears to be a unique and direct association between NSSI and suicide attempts. Gateway Theory One of the theories that proposes a unique and direct association between NSSI and suicide is the gateway theory. This theory proposes that NSSI and suicide attempt exist on a continuum of self-​harming behavior, with low severity self-​ harming behavior that involves only mild tissue damage on one end of the continuum and the most severe type of self-​injury, suicide attempt, on the other end (Stanley, Winchel, Molcho, Simeon, & Stanley, 1992). These theorists argue that NSSI is just a lesser form of self-​injurious behavior (Stanley et al., 1992), it works as a gateway for more serious self-​injurious behaviors, paving the path for suicide attempt (Hamza et al., 2012). This theory makes several predictions: (1) NSSI should predict suicide attempt longitudinally; (2) onset of NSSI should be earlier than suicide attempt; (3) severity of NSSI should increase before the suicide attempt; (4) more severe or more frequent NSSI should predict more severe or more frequent suicide attempts; and (5) the predictive value of NSSI should remain significant when other variables that are associated with suicidal behaviors are controlled. Many of these predictions have been supported by research. It has been established that NSSI has an earlier age of onset in comparison to suicidal self-​ harming behaviors and precedes suicide attempt chronologically (Groschwitz et  al., 2015; Ougrin et  al., 2012). It has also been established in both cross-​ sectional and longitudinal studies that NSSI predicts suicide attempt (Asarnow et al., 2011; Brunner et al., 2007; Glenn & Klonsky, 2009; Hamza & Willoughby, 2014; Prinstein et al., 2008; Zlotnick et al., 1997). As mentioned previously, in longitudinal studies, even though NSSI predicted future suicide attempts, suicide attempts did not predict future NSSI (Asarnow et al., 2011;Wilkinson et al., 2011). These findings support the theory that NSSI acts as a gateway for suicide attempts. Studies also support an association between the severity of NSSI and risk of suicide attempts. For instance, studies have found that more frequent NSSI is associated with more severe suicidality, including a higher likelihood of having a history of suicide attempt and greater number of lifetime suicide attempts (Brunner et al., 2007). A similar pattern was observed in a sample of Chinese adolescents: NSSI frequency prospectively predicted suicide attempts over the next six months, an association that remained even when adjusting for shared risk factors (You & Lin, 2015). Acquired Capability The concept of acquired capability for suicide, introduced in Thomas Joiner’s interpersonal theory of suicide (Joiner, 2005), may also help explain

Nonsuicidal and Suicidal Self-Injury  115

the NSSI–​suicide relationship. Joiner’s theory suggests that while feelings of thwarted belongingness and burdensomeness are necessary for suicidal desire, the desire to end one’s life does not directly translate to a suicide attempt; indeed, people are evolutionarily predisposed to be afraid of pain, injury, and death, creating a strong drive to avoid them. Hence, an individual with suicidal desire can only progress toward a suicide attempt if they can overcome their fear of pain, injury, and death. According to Joiner (2005), the ability to overcome these fears and to make a suicide attempt can be acquired through life experiences that habituate people to pain, injury, and death. From this perspective, painful or provocative experiences, such as history of child abuse, occupational exposure to death, histories of substance use or eating disorder behaviors that involve self-​inflicted damage, and countless other types of painful and provocative experiences, expose people to their fears of pain, injury, and death, making them more comfortable and accustomed to the idea of harming themselves, and thus more capable of overcoming these barriers and attempting suicide (Van Orden et al., 2010). Joiner’s theory can help explain NSSI’s association with suicide attempts. NSSI can be considered a painful and provocative experience, whereby a pattern of self-​ inflicted injury and pain can cause habituation to these factors that normally serve as strong barriers to attempting suicide (Joiner, 2005). Thus, the association between NSSI and suicide could be explained as follows: NSSI should increase acquired capability for suicide, and therefore, more frequent, severe, and/​or persistent NSSI should be associated with higher risk of suicide attempt, especially among those disposed to suicidal ideation/​desire. There is some evidence to support these hypotheses. In one study, those who engaged in NSSI had elevated acquired capability for suicide (Franklin, Hessel, & Prinstein, 2011). Further, NSSI is associated with indices of lower pain sensitivity and higher pain tolerance in laboratory studies. These results suggest that people who engage in NSSI may habituate to pain relative to noninjurers, and that their heightened acquired capability for suicide may at least be partly due to lower pain sensitivity. For example, one study found that those who experience less pain during NSSI are more likely to attempt suicide (Nock et al., 2006), which is consistent with the idea that habituation to pain increases the capability for attempting suicide. Of course, as Franklin and colleagues (2011) suggest, it is also possible that the causal arrow is reversed in that NSSI causes lower pain sensitivity, and lower pain sensitivity increases risk for NSSI and suicide attempts. Longitudinal research on the course of pain sensitivity and NSSI or suicide attempts is required to distinguish these possibilities. There is also some evidence for reduced fear of death and fear of suicide in those who engage in NSSI. One study reported that among patients with personality disorders, those with NSSI histories were more likely to refer to death as a never-​ending sleep or as a means to be reunited with loved ones and were more confident in their ability to attempt suicide (Stanley, Gameroff, Michalsen,

116  Bita Zareian and E. David Klonsky

& Mann, 2001). Given the limited evidence available, however, the association between NSSI and reduced fear of death is a worthy focus of future research. If that pathway from NSSI to suicide attempts occurs through a greater acquired capability for suicide, we would also expect that higher frequency of NSSI, more severe methods of NSSI, greater number of NSSI methods used, and longer duration for NSSI should be associated with suicide attempts. A comprehensive review of suicide attempt correlates among self-​injurers confirms this prediction (Victor & Klonsky, 2014). These findings will be described in more detail below in this chapter’s final section, which addresses characteristics of NSSI that relate most strongly to histories of suicide attempts and suicide risk.

Predictors of Suicide Attempts and Risk among Self-​I njurers Given that individuals with NSSI are at heightened suicide risk, it is important to identify the characteristics of self-​injurers that may suggest greatest risk. Several characteristics of NSSI are associated with indicators of suicidal behavior, including the frequency of NSSI, number of methods used for NSSI, and the type of NSSI. With regard to frequency of NSSI, even though some studies have not found an association between frequency of NSSI and history of suicide attempt (Nock et al., 2006; Tresno, Ito, & Mearns, 2012), most studies have found that a higher frequency of NSSI is associated with a greater likelihood of suicidality or more severe suicidality (Groschwitz et al., 2015; Lloyd-​Richardson et al., 2007;Turner, Layden, Butler, & Chapman, 2013; Whitlock & Knox, 2007). For instance, studies assessing NSSI in clinical and community samples found that the frequency of NSSI predicted greater likelihood of suicide ideation, suicide plan, suicide attempt, and history of multiple attempts (Brunner et al., 2007; Dulit, Fyer, Leon, Brodsky, & Frances, 1994). Aggregating across all relevant studies, the frequency of NSSI is moderately associated with history of suicide attempt (Victor & Klonsky, 2014). Another aspect of NSSI that predicts suicidality is the diversity of methods used for NSSI. Several studies have shown that the more methods of NSSI one has utilized (e.g., cutting, scraping, banging, burning, imbedding), the more likely the person is to engage in suicidal behavior (Lloyd-​Richardson et  al., 2007; Nock et al., 2006). Similar to the association between frequency of NSSI and suicidality, a moderate strength of association was found between number of NSSI methods and suicide attempt (Victor & Klonsky, 2014). In addition to frequency and number of methods used for NSSI, the type of NSSI method used is also associated with suicidality. It has been found that more severe types of NSSI, such as cutting and burning, are associated with more severe current suicide ideation, higher likelihood of having a history of suicide attempt, and greater number of past suicide attempts, in comparison to less severe types of NSSI, such as self-​hitting and hair-​pulling (Favaro et al.,

Nonsuicidal and Suicidal Self-Injury  117

2008; Lloyd-​Richardson et al., 2007). Cutting also appears to be associated with suicide attempt history more than other types of NSSI, although the association between cutting and suicide attempt history is only modest (Victor & Klonsky, 2014). The association between suicidal behavior and NSSI frequency and number of methods are consistent with the third variable, gateway, and acquired capability perspectives. For instance, more frequent, diverse, and severe NSSI represent more frequent and diverse experiences with self-​inflicted pain and injury, serving as a gateway and increasing capability for suicide attempts. In addition, it is likely that increased frequency, diversity, and severity of NSSI indicates more severe psychopathology, which itself is associated with higher likelihood of suicidal behavior. In addition to the characteristics of the NSSI itself, there are a variety of psychosocial characteristics of self-​injurers that appear to raise risk for suicide attempts. These include suicidal ideation, hopelessness, impulsivity, borderline personality disorder (BPD), post​traumatic stress disorder (PTSD), and depression. Several studies have found that suicide ideation is higher among NSSI subjects with a history of suicide attempt than those without a history of suicide attempt (Claes et al., 2010; Cloutier et al., 2010; Jacobson et al., 2008) and that suicide ideation is the strongest predictor of suicide attempt is this population (Dougherty et al., 2009; Victor & Klonsky, 2014). For instance, in a community sample of adolescents, suicide ideation was significantly higher among participants with both history of NSSI and suicide attempt in comparison to those with only history of NSSI (Brausch & Gutierrez, 2010). Among a sample of adult psychiatric inpatients, NSSI was significantly correlated with suicide attempt after controlling for suicide ideation, depression, and BPD, and suicide ideation was the only variable that remained significantly associated with suicide attempt, apart from NSSI (Andover & Gibb, 2010). Hopelessness (Asarnow et al., 2011; Brausch & Gutierrez, 2010; Dougherty et  al., 2009; Taliaferro & Muehlenkamp, 2015; Taliaferro, Muehlenkamp, Borowsky, McMorris, & Kugler, 2012) and impulsivity (Cloutier et  al., 2010; Dougherty et  al., 2009; Maloney, Degenhardt, Darke, & Nelson, 2010; Muehlenkamp et al., 2011) are two other psychological variables associated with suicide attempt among those with NSSI. Both variables exhibited modest associations with suicide attempt histories in a meta-​analysis examining predictors of suicide attempt history among self-​injurers (Victor & Klonsky, 2014). It is important to note, however, that impulsivity is not a homogeneous construct and different facets of impulsivity may relate differently to suicide attempt (Victor & Klonsky, 2014). For instance, Dougherty and colleagues (2009) found that both hopelessness and impulsivity were higher in NSSI patients with a history of suicide attempt than those with no history of suicide attempt; however, the association between impulsivity and history of suicide attempt varied by the type of measures of impulsivity analyzed. Self-​report impulsivity and a behavioral measure of impulsivity that assessed consequence sensitivity were strong

118  Bita Zareian and E. David Klonsky

predictors of suicide attempt in this sample, whereas a behavioral measure of impulsivity that assessed response inhibition did not relate to suicide attempt history (Dougherty et al., 2009). BPD is another variable associated with risk of suicide attempt among people with NSSI (Jacobson et  al., 2008; Maloney et  al., 2010; Muehlenkamp et  al., 2011). The magnitude of this association is moderate, yet BPD remains strongly associated with mental disorders and suicide attempt among those with NSSI (Victor & Klonsky, 2014). These findings, however, should be interpreted with caution, as suicidal behavior is a symptom of BPD and most studies examining predictors of suicide attempt among self-​injurers have not removed this confound (Victor & Klonsky, 2014). In fact, one study that addressed the confound by omitting the suicidality criterion of BPD (Jacobson et al., 2008) reported a relatively small association between BPD and suicide attempt history. Thus, it is possible that the association reported in the Victor and Klonsky (2014) meta-​ analysis may overestimate the association of BPD with suicide attempts among self-​injurers. Depression and anxiety are mental disorders that have also been examined in relation to suicide attempt in NSSI samples (Asarnow et al., 2011; Brausch & Gutierrez, 2010; Cloutier et al., 2010; Dougherty et al., 2009; Jacobson et al., 2008; Jenkins, Singer, Conner, Calhoun, & Diamond, 2014; Polanco-​Roman et al., 2015; Taliaferro & Muehlenkamp, 2015; Taliaferro et al., 2012). The effect sizes for these associations, however, have been found to be small to moderate for depression and anxiety (Victor & Klonsky, 2014). Interestingly, when PTSD is assessed separately from other anxiety disorders, it predicts suicide attempt among NSSI participants with a moderate effect size (Jacobson et  al., 2008; Jenkins et al., 2014; Maloney et al., 2010;Victor & Klonsky, 2014). Studies have found mixed results when examining the association between histories of sexual and physical abuse and suicide attempt in NSSI samples.Whereas some studies have failed to find a significant difference between participants with only NSSI history and those with both NSSI and suicide attempt history on these two variables (Dougherty et al., 2009), other studies have found one or both of these variables to be significantly greater in participants with history of both suicide attempt and NSSI (Asarnow et al., 2011; Boxer, 2010; Chapman, Gratz, & Turner, 2014; Taliaferro & Muehlenkamp, 2015). On average, it seems that both of these variables have a small association with suicide attempt h ­ istories among injurers (Victor & Klonsky, 2014). Demographic variables have also been assessed in relation to suicide attempt among participants with NSSI. In most studies, age and ethnicity were not significantly different between NSSI subjects with or without history of suicide attempt (Asarnow et  al., 2011; Cloutier et  al., 2010; Dougherty et  al., 2009; Jacobson et al., 2008). With regard to gender, some studies show that females with NSSI are more likely to have a history of attempted suicide (Asarnow et al., 2011), whereas other studies found no gender difference between NSSI groups with or without a history of suicide attempt (Jacobson et al., 2008). On

Nonsuicidal and Suicidal Self-Injury  119

average, it seems that gender slightly differentiates between NSSI participants with history of suicide attempt from those without a history of suicide attempt, with women being somewhat more likely to attempt suicide (Victor & Klonsky, 2014).

Conclusion The association between NSSI and suicidal behavior is a critically important public health concern. NSSI is distinct from suicide attempts based on intent, medical severity, frequency, and prevalence among other factors. Although individuals who self-​injure should not be assumed to be suicidal, NSSI confers higher risk for suicide attempts because it is associated with risk factors for both suicidal desire (e.g., depression, hopelessness, burdensomeness, and thwarted belongingness) and the ability to attempt suicide (e.g., acquired capability). In clinical settings, any indication of NSSI, both past and present, suggests the need to assess carefully for suicidal ideation and behavior, and to develop a sound safety plan if risk for suicide is identified. In this manner, clinicians can avoid misunderstanding NSSI as a form of suicide while still appreciating its implications for suicide risk.

References American Psychiatric Association. (1980). Diagnostic and statistical manual of mental disorders (3rd ed.): Washington, DC: American Psychiatric Association. American Psychiatric Association. (1987). Diagnostic and statistical manual of mental disorders (3rd ed., rev). Washington, DC: American Psychiatric Association. American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: American Psychiatric Association. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: American Psychiatric Association. Andover, M. S., & Gibb, B. E. (2010). Non-​suicidal self-​injury, attempted suicide, and suicidal intent among psychiatric inpatients. Psychiatry Research, 178(1), 101–​ 105. doi:10.1016/​j.psychres.2010.03.019 Asarnow, J.  R., Porta, G., Spirito, A., Emslie, G., Clarke, G., Wagner, K.  D., … Brent, D. A. (2011). Suicide attempts and nonsuicidal self-​injury in the treatment of resistant depression in adolescents:  Findings from the TORDIA study. Journal of the American Academy of Child & Adolescent Psychiatry, 50(8), 772–​781. doi:10.1016/​j.jaac.2011.04.003 Baetens, I., Claes, L., Muehlenkamp, J., Grietens, H., & Onghena, P. (2011). Non-​suicidal and suicidal self-​injurious behavior among Flemish adolescents: A web-​survey. Archives of Suicide Research, 15(1), 56–​67. doi:10.1080/​13811118.2011.540467 Boxer, P. (2010). Variations in risk and treatment factors among adolescents engaging in different types of deliberate self-​harm in an inpatient sample. Journal of Clinical Child and Adolescent Psychology, 39(4), 470–​480. doi:10.1080/​15374416.2010.486302 Brausch, A. M., & Gutierrez, P. M. (2009). The role of body image and disordered eating as risk factors for depression and suicidal ideation in adolescents. Suicide and Life-​ Threatening Behavior, 39(1), 58–​71. doi:10.1521/​suli.2009.39.1.58

120  Bita Zareian and E. David Klonsky Brausch, A.  M., & Gutierrez, P.  M. (2010). Differences in non-​ suicidal self-​ injury and suicide attempts in adolescents. Journal of Youth and Adolescence, 39(3), 233–​242. doi:10.1007/​s10964-​009-​9482-​0 Brown, M. Z., Comtois, K. A., & Linehan, M. M. (2002). Reasons for suicide attempts and nonsuicidal self-​injury in women with borderline personality disorder. Journal of Abnormal Psychology, 111(1), 198–​202. doi:10.1037/​0021-​843X.111.1.198 Brunner, R., Parzer, P., Haffner, J., Steen, R., Roos, J., Klett, M., & Resch, F. (2007). Prevalence and psychological correlates of occasional and repetitive deliberate self-​ harm in adolescents. Archives of Pediatrics & Adolescent Medicine, 161(7), 641–​ 649. doi:10.1001/​archpedi.161.7.641 Chapman, A.  L., Gratz, K.  L., & Turner, B.  J. (2014). Risk-​ related and protective correlates  of nonsuicidal self-​ injury and co-​ occurring suicide attempts among incarcerated women. Suicide and Life-​Threatening Behavior, 44(2), 139–​154. doi:10.1111/ ​sltb.12058 Cheung, Y. T. D., Wong, P. W. C., Lee, A. M., Lam, T. H., Fan, Y. S. S., & Yip, P. S. F. (2013). Non-​suicidal self-​injury and suicidal behavior: Prevalence, co-​occurrence, and correlates of suicide among adolescents in Hong Kong. Social Psychiatry and Psychiatric Epidemiology, 48(7), 1133–​1144. doi:10.1007/​s00127-​012-​0640-​4 Claes, L., Muehlenkamp, J., Vandereycken, W., Hamelinck, L., Martens, H., & Claes, S. (2010). Comparison of non-​suicidal self-​injurious behavior and suicide attempts in patients admitted to a psychiatric crisis unit. Personality and Individual Differences, 48(1), 83–​87. doi:10.1016/​j.paid.2009.09.001 Cloutier, P., Martin, J., Kennedy, A., Nixon, M.  K., & Muehlenkamp, J.  J. (2010). Characteristics and co-​occurrence of adolescent non-​suicidal self-​injury and suicidal behaviors in pediatric emergency crisis services. Journal of Youth and Adolescence, 39(3), 259–​269. doi:10.1007/​s10964-​009-​9465-​1 Dougherty, D. M., Mathias, C. W., Marsh-​Richard, D. M., Prevette, K. N., Dawes, M. A., Hatzis, E.  S., … Nouvion, S.  O. (2009). Impulsivity and clinical symptoms among adolescents with non-​suicidal self-​injury with or without attempted suicide. Psychiatry Research, 169(1), 22–​27. doi:10.1016/​j.psychres.2008.06.011 Dulit, R. A., Fyer, M. R., Leon, A. C., Brodsky, B. S., & Frances, A. J. (1994). Clinical correlates of self-​mutilation in borderline personality disorder. The American Journal of Psychiatry, 151(9), 1305–​1311. doi:10.1176/​ajp.151.9.1305 Favaro, A., Santonastaso, P., Monteleone, P., Bellodi, L., Mauri, M., Rotond, A., … Maj, M. (2008). Self-​injurious behavior and attempted suicide in purging bulimia nervosa: Associations with psychiatric comorbidity. Journal of Affective Disorders, 105(1–​3), 285–​289. doi:10.1016/​j.jad.2007.05.010 Franklin, J. C., Hessel, E. T., & Prinstein, M. J. (2011). Clarifying the role of pain tolerance in suicidal capability. Psychiatry Research, 189(3), 362–​ 367. doi:10.1016/​ j.psychres.2011.08.001 Garrison, C. Z., Addy, C. L., McKeown, R. E., Cuffe, S. P., Jackson, K. L., & Waller, J. L. (1993). Nonsuicidal physically self-​damaging acts in adolescents. Journal of Child and Family Studies, 2(4), 339–​352. doi:10.1007/​BF01321230 Glenn, C.  R., & Klonsky, E.  D. (2009). Social context during non-​suicidal self-​injury indicates suicide risk. Personality and Individual Differences, 46(1), 25–​29. doi:10.1016/​ j.paid.2008.08.020 Gratz, K. (2001). Measurement of deliberate self-​harm: Preliminary data on the Deliberate Self-​Harm Inventory. Journal of Psychopathology and Behavioral Assessment, 23(4), 253–​263. doi:10.1023/​A:1012779403943

Nonsuicidal and Suicidal Self-Injury  121 Groschwitz, R. C., Kaess, M., Fischer, G., Ameis, N., Schulze, U. M. E., Brunner, R., … Plener, P. L. (2015). The association of non-​suicidal self-​injury and suicidal behavior according to DSM-​5 in adolescent psychiatric inpatients. Psychiatry Research, 228(3), 454–​461. doi:10.1016/​j.psychres.2015.06.019 Guan, K., Fox, K. R., & Prinstein, M. J. (2012). Nonsuicidal self-​injury as a time-​invariant predictor of adolescent suicide ideation and attempts in a diverse community sample. Journal of Consulting and Clinical Psychology, 80(5), 842–​849. doi:10.1037/​a0029429 Hamza, C.  A., Stewart, S.  L., & Willoughby, T. (2012). Examining the link between nonsuicidal self-​injury and suicidal behavior: A review of the literature and an integrated model. Clinical Psychology Review, 32(6), 482–​495. doi:10.1016/​j.cpr.2012.05.003 Hamza, C. A., & Willoughby, T. (2014). A longitudinal person-​centered examination of nonsuicidal self-​injury among university students. Journal of Youth and Adolescence, 43(4), 671–​685. doi:10.1007/​s10964-​013-​9991-​8 Hawton, K., Rodham, K., Evans, E., & Weatherall, R. (2002). Deliberate self harm in adolescents:  Self report survey in schools in England. BMJ:  British Medical Journal, 325(7374), 1207–​1211. doi:10.1136/​bmj.325.7374.1207 Isometsä, E. T., & Lönnqvist, J. K. (1998). Suicide attempts preceding completed suicide. The British Journal of Psychiatry, 173, 531–​535. doi:10.1192/​bjp.173.6.531 Jacobson, C.  M., Muehlenkamp, J.  J., Miller, A.  L., & Turner, J.  B. (2008). Psychiatric impairment among adolescents engaging in different types of deliberate self-​harm. Journal of Clinical Child and Adolescent Psychology, 37(2), 363–​ 375. doi:10.1080/​ 15374410801955771 Jenkins, A.  L., Singer, J., Conner, B.  T., Calhoun, S., & Diamond, G. (2014). Risk for suicidal ideation and attempt among a primary care sample of adolescents engaging in nonsuicidal self-​ injury. Suicide and Life-​ Threatening Behavior, 44(6), 616–​ 628. doi:10.1111/​sltb.12094 Joiner, T. (2005). Why people die by suicide. Cambridge, MA: Harvard University Press. Kim, K.  L., Galvan, T., Puzia, M.  E., Cushman, G.  K., Seymour, K.  E., Vanmali, R., … Dickstein, D.  P. (2015). Psychiatric and self-​injury profiles of adolescent suicide attempters versus adolescents engaged in nonsuicidal self-​ injury. Suicide and Life-​ Threatening Behavior, 45(1), 37–​50. doi:10.1111/​sltb.12110 Klonsky, E. D. (2007). The functions of deliberate self-​injury: A review of the evidence. Clinical Psychology Review, 27(2), 226–​239. doi:10.1016/​j.cpr.2006.08.002 Klonsky, E.  D. (2011). Non-​ suicidal self-​ injury in United States adults:  Prevalence, sociodemographics, topography and functions. Psychological Medicine, 41(9), 1981–​ 1986. doi:10.1017/​S0033291710002497 Klonsky, E. D., May, A. M., & Glenn, C. R. (2013). The relationship between nonsui­ cidal self-​ injury and attempted suicide:  Converging evidence from four samples. Journal of Abnormal Psychology, 122(1), 231–​237. doi:10.1037/​a0030278 Laye-​Gindhu, A., & Schonert-​Reichl, K. A. (2005). Nonsuicidal self-​harm among community adolescents:  Understanding the “whats” and “whys” of self-​harm. Journal of Youth and Adolescence, 34(5), 447–​457. doi:10.1007/​s10964-​005-​7262-​z Lloyd-​Richardson, E. E., Perrine, N., Dierker, L., & Kelley, M. L. (2007). Characteristic and functions on non-​suicidal self-​injury in a community sample of adolescents. Psychological Medicine, 37(8), 1183–​1192. doi:10.1017/​S003329170700027X Maloney, E., Degenhardt, L., Darke, S., & Nelson, E.  C. (2010). Investigating the co-​occurrence of self-​mutilation and suicide attempts among opioid-​dependent individuals. Suicide and Life-​ Threatening Behavior, 40(1), 50–​ 62. doi:10.1521/​ suli. 2010.40.1.50

122  Bita Zareian and E. David Klonsky Mars, B., Heron, J., Crane, C., Hawton, K., Kidger, J., Lewis, G., … Gunnell, D. (2014). Differences in risk factors for self-​harm with and without suicidal intent:  Findings from the ALSPAC cohort. Journal of Affective Disorders, 168, 407–​414. doi:10.1016/​ j.jad.2014.07.009 Martin, G., Swannell, S. V., Hazell, P. L., Harrison, J. E., & Taylor, A. W. (2010). Self-​injury in Australia: A community survey. Medical Journal of Australia, 193(9), 506–​510. Menninger, K. A. (1938). Man against himself. Oxford: Harcourt, Brace. Muehlenkamp, J.  J. (2005). Self-​ injurious behavior as a separate clinical syndrome. American Journal of Orthopsychiatry, 75(2), 324–​333. doi:10.1037/​0002-​9432.75.2.324 Muehlenkamp, J. J., Ertelt, T. W., Miller, A. L., & Claes, L. (2011). Borderline personality symptoms differentiate non-​suicidal and suicidal self-​injury in ethnically diverse adolescent outpatients. Journal of Child Psychology and Psychiatry, 52(2), 148–​ 155. doi:10.1111/​j.1469-​7610.2010.02305.x Muehlenkamp, J. J., & Gutierrez, P. M. (2004). An investigation of differences between self-​injurious behavior and suicide attempts in a sample of adolescents. Suicide and Life-​ Threatening Behavior, 34(1), 12–​23. doi:10.1521/​suli.34.1.12.27769 Muehlenkamp, J.  J., & Gutierrez, P.  M. (2007). Risk for suicide attempts among adolescents who engage in non-​suicidal self-​injury. Archives of Suicide Research, 11(1), 69–​82. doi:10.1080/​13811110600992902 Kapur, N., Cooper, J., O’Connor, R., & Hawton, K. (2013). Non-​suicidal self-​injury v. attempted suicide: New diagnosis or false dichotomy? British Journal of Psychiatry, 202(5), 326–​328. doi:10.1192/​bjp.bp.112.116111 Nixon, M. K., Cloutier, P. F., & Aggarwal, S. (2002).Affect regulation and addictive aspects of repetitive self-​injury in hospitalized adolescents. Journal of the American Academy of Child & Adolescent Psychiatry, 41(11), 1333–​1341. doi:10.1097/​00004583-​200211000-​00015 Nock, M.  K. (2010). Self-​ injury. Annual Review of Clinical Psychology, 6, 339–​ 363. doi:10.1146/​annurev.clinpsy.121208.131258 Nock, M.  K., Holmberg, E.  B., Photos, V.  I., & Michel, B.  D. (2007). The Self-​ Injurious Thoughts and Behaviors Interview:  Development, reliability, and validity in an adolescent sample. Psychological Assessment, 19(3), 309–​ 317. doi:10.1037/​ 1040-​3590.19.3.309 Nock, M.  K., Joiner, T.  E., Jr., Gordon, K.  H., Lloyd-​ Richardson, E., & Prinstein, M.  J. (2006). Non-​ suicidal self-​ injury among adolescents:  Diagnostic correlates and relation to suicide attempts. Psychiatry Research, 144(1), 65–​ 72. doi:10.1016/​ j.psychres.2006.05.010 Nock, M. K., & Kessler, R. C. (2006). Prevalence of and risk factors for suicide attempts versus suicide gestures:  Analysis of the National Comorbidity Survey. Journal of Abnormal Psychology, 115(3), 616–​623. doi:10.1037/​0021-​843X.115.3.616 O’Carroll, P. W., Berman, A., Maris, R. W., Moscicki, E. K., Tanney, B. L., & Silverman, M. M. (1996). Beyond the tower of Babel: A nomenclature for suicidology. Suicide and Life-​Threatening Behavior, 26(3), 237–​252. Ogundipe, L.  O. (1999). Suicide attempts v.  deliberate self-​ harm. British Journal of Psychiatry, 175(1), 90–​90. doi:10.1192/​bjp.175.1.90a Orlando, C. M., Broman-​Fulks, J. J., Whitlock, J. L., Curtin, L., & Michael, K. D. (2015). Nonsuicidal self-​injury and suicidal self-​injury:  A taxometric investigation. Behavior Therapy, 46(6), 824–​833. doi:10.1016/​j.beth.2015.01.002 Ougrin, D., Zundel, T., Kyriakopoulos, M., Banarsee, R., Stahl, D., & Taylor, E. (2012). Adolescents with suicidal and nonsuicidal self-​ harm:  Clinical characteristics and

Nonsuicidal and Suicidal Self-Injury  123 response to therapeutic assessment. Psychological Assessment, 24(1), 11–​20. doi:10.1037/​ a0025043 Patton, G. C., Harris, R., Carlin, J. B., Hibbert, M. E., Coffey, C., Schwartz, M., & Bowes, G. (1997). Adolescent suicidal behaviors: A population-​based study of risk. Psychological Medicine, 27(3), 715–​724. doi:10.1017/​S003329179600462X Paul, E., Tsypes, A., Eidlitz, L., Ernhout, C., & Whitlock, J. (2015). Frequency and functions  of non-​ suicidal self-​ injury:  Associations with suicidal thoughts and behaviors. Psychiatry Research, 225(3), 276–​282. doi:10.1016/​j.psychres.2014.12.026 Polanco-​Roman, L., Jurska, J., Quiñones,V., & Miranda, R. (2015). Brooding, reflection, and distraction: Relation to non-​suicidal self-​injury versus suicide attempts. Archives of Suicide Research, 19(3), 350–​365. doi:10.1080/​13811118.2014.981623 Prinstein, M.  J., Nock, M.  K., Simon, V., Aikins, J.  W., Cheah, C.  S.  L., & Spirito, A. (2008).  Longitudinal trajectories and predictors of adolescent suicidal ideation and attempts following inpatient hospitalization. Journal of Consulting and Clinical Psychology, 76(1), 92–​103. doi:10.1037/​0022-​006X.76.1.92 Rodav, O., Levy, S., & Hamdan, S. (2014). Clinical characteristics and functions of non-​suicide self-​injury in youth. European Psychiatry, 29(8), 503–​508. doi:10.1016/​ j.eurpsy.2014.02.008 Ross, S., & Heath, N. (2002). A study of the frequency of self-​mutilation in a community sample of adolescents. Journal of Youth and Adolescence, 31(1), 67–​77. doi:10.1023/​ A:1014089117419 Saraff, P. D., & Pepper, C. M. (2014). Functions, lifetime frequency, and variety of methods of non-​suicidal self-​injury among college students. Psychiatry Research, 219(2), 298–​ 304. doi:10.1016/​j.psychres.2014.05.044 Schwartz, R. H., Cohen, P., Hoffmann, N. G., & Meeks, J. E. (1989). Self-​harm behaviors (carving) in female adolescent drug abusers. Clinical Pediatrics, 28(8), 340–​ 346. doi:10.1177/​000992288902800801 Shearer, S. L. (1994). Phenomenology of self-​injury among inpatient women with borderline personality disorder. Journal of Nervous and Mental Disease, 182(9), 524–​526. Stanley, B., Gameroff, M. J., Michalsen, V., & Mann, J. J. (2001). Are suicide attempters who self-​mutilate a unique population? The American Journal of Psychiatry, 158(3), 427–​ 432. doi:10.1176/​appi.ajp.158.3.427 Stanley, B., Winchel, R., Molcho, A., Simeon, D., & Stanley, M. (1992). Suicide and the self-​ harm continuum:  Phenomenological and biochemical evidence. International Review of Psychiatry, 4(2), 149–​155. doi:10.3109/​09540269209066312 Taliaferro, L. A., & Muehlenkamp, J. J. (2015). Risk factors associated with self-​injurious behavior among a national sample of undergraduate college students. Journal of American College Health, 63(1), 40–​48. doi:10.1080/​07448481.2014.953166 Taliaferro, L. A., Muehlenkamp, J. J., Borowsky, I. W., McMorris, B. J., & Kugler, K. C. (2012). Factors distinguishing youth who report self-​injurious behavior: A population-​ based sample. Academic Pediatrics, 12(3), 205–​213. Tang, J., Yu, Y., Wu, Y., Du, Y., Ma, Y., Zhu, H., … Liu, Z. (2011). Association between non-​ suicidal self-​ injuries and suicide attempts in Chinese adolescents and college students:  A cross-​section study. PLoS ONE, 6(4). doi:10.1371/​journal. pone.0017977 Tapola,V., Wahlström, J., Kuittinen, M., & Lappalainen, R. (2015). The co-​occurrence of nonsuicidal and suicidal self-​injurious acts in adult women: A pilot study of similarities and differences. Nordic Psychology, 67(1), 27–​45. doi:10.1080/​19012276.2014.997784

124  Bita Zareian and E. David Klonsky Tresno, F., Ito, Y., & Mearns, J. (2012). Self-​injurious behavior and suicide attempts among Indonesian college students. Death Studies, 36(7), 627–​ 639. doi:10.1080/​ 07481187.2011.604464 Turner, B. J., Layden, B. K., Butler, S. M., & Chapman, A. L. (2013). How often, or how many ways: Clarifying the relationship between non-​suicidal self-​injury and suicidality. Archives of Suicide Research, 17(4), 397–​415. doi:10.1080/​13811118.2013.802660 Van Orden, K.  A., Witte, T.  K., Cukrowicz, K.  C., Braithwaite, S.  R., Selby, E.  A., & Joiner,T. E., Jr. (2010).The interpersonal theory of suicide. Psychological Review, 117(2), 575–​600. doi:10.1037/​a0018697 Victor, S. E., Davis,T., & Klonsky, E. D. (2017). Descriptive characteristics and initial psychometric properties of the non-​suicidal selfinjury disorder scale. Archives of Suicide Research, 21(2), 265–​278. doi:10.1080/​13811118.2016.1193078 Victor, S.  E., & Klonsky, E.  D. (2014). Correlates of suicide attempts among self-​ injurers:  A meta-​analysis. Clinical Psychology Review, 34(4), 282–​297. doi:10.1016/​ j.cpr.2014.03.005 Washburn, J. J., Potthoff, L. M., Juzwin, K. R., & Styer, D. M. (2015). Assessing DSM-​5 nonsuicidal self-​injury disorder in a clinical sample. Psychological Assessment, 27(1), 31–​41. doi:10.1037/​pas0000021. Whitlock, J., & Knox, K. L. (2007). The relationship between self-​injurious behavior and suicide in a young adult population. Archives of Pediatrics & Adolescent Medicine, 161(7), 634–​640. doi:10.1001/​archpedi.161.7.634 Whitlock, J., Muehlenkamp, J., & Eckenrode, J. (2008). Variation in nonsuicidal self-​ injury: Identification and features of latent classes in a college population of emerging adults. Journal of Clinical Child and Adolescent Psychology, 37(4), 725–​735. doi:10.1080/​ 15374410802359734 Whitlock, J., Muehlenkamp, J., Eckenrode, J., Purington, A., Baral Abrams, G., Barreira, P., & Kress, V. (2013). Nonsuicidal self-​injury as a gateway to suicide in young adults. Journal of Adolescent Health, 52(4), 486–​492. doi:10.1016/​j.jadohealth.2012.09.010 Wilkinson, P., Kelvin, R., Roberts, C., Dubicka, B., & Goodyer, I. (2011). Clinical and ­psychosocial predictors of suicide attempts and nonsuicidal self-​injury in the Adolescent  Depression Antidepressants and Psychotherapy Trial (ADAPT). The American Journal of Psychiatry, 168(5), 495–​501. doi:10.1176/​appi.ajp.2010.10050718 You, J., & Lin, M.-​P. (2015). Predicting suicide attempts by time-​varying frequency of nonsuicidal self-​injury among Chinese community adolescents. Journal of Consulting and Clinical Psychology, 83(3), 524–​533. doi:10.1037/​a0039055 Zlotnick, C., Donaldson, D., Spirito, A., & Pearlstein, T. (1997). Affect regulation and suicide attempts in adolescent inpatients. Journal of the American Academy of Child & Adolescent Psychiatry, 36(6), 793–​798. doi:10.1097/​00004583-​199706000-​00016

Section III

Assessment and Treatment

Chapter 8

Comprehensive Assessment of Nonsuicidal Self-​I njury Gregory J. Lengel and Denise Styer

Introduction The assessment of nonsuicidal self-​injury (NSSI) can be complex and challenging. NSSI assessment requires careful examination of several variables, the use of multiple methods, attention to an individual’s demeanor, the development of rapport, as well as the identification and prioritization of goals that often vary depending on the context of the assessment. Further adding to the challenge of clinical assessment of NSSI is that the time available for evaluation and clinical decision-​making is often limited in real-​world clinical contexts. Additionally, assessment does not stop after the initial screening; ongoing assessment of NSSI is necessary over the course of treatment due to the mutability of NSSI urges and behaviors over time. This chapter reviews the elements involved in a comprehensive clinical assessment of NSSI. While we will discuss many established NSSI assessment tools and strategies below, it is important to emphasize that no single measure, interview, or assessment framework is sufficient for the clinical assessment of NSSI. Therefore, rather than provide details of specific assessment measures, we instead review the critical variables and constructs essential to a comprehensive NSSI assessment.

Initial Screening Given the association of NSSI with other mental disorders, especially suicide, screening for NSSI should be a routine component of all clinical assessments, regardless of presenting concerns. During the initial intake assessment, clinical assessors should identify if the client has current and past urges to harm his or her self, as well as whether he or she previously engaged, or is presently engaging, in NSSI. When screening for NSSI specifically, it is necessary to differentiate between NSSI and other forms of direct self-​harm (e.g., suicidal behavior, indirect self-​harm) by determining if the self-​injurious behaviors meet the definition of NSSI, that is the “direct, deliberate destruction of one’s own body tissue in the absence of suicidal intent” (Nock & Favazza, 2009, p.  9). Differentiating NSSI from self-​harming behavior can be accomplished

128  Gregory J. Lengel and Denise Styer

by simply and directly asking the client questions such as, “Have you ever purposely caused physical harm to yourself without the intention of ending your life?” and “Have you ever purposely attempted to end your life?” during an intake interview, or through the administration of NSSI-​specific self-​report measures. Once NSSI behavior has been identified, we recommend that an accurate and thorough assessment of the self-​injurious thoughts and behaviors be conducted.

History and Severity A comprehensive examination of the client’s NSSI history is a recommended starting point for clinical assessment of NSSI. A thorough history will include information concerning the onset of the behavior, such as the date of initial injury, date of most recent NSSI episode, the frequency, methods, and tools utilized during each period of NSSI, as well as factors that may have led to the onset of NSSI and the context in which the NSSI occurred (e.g., location, specific prompting events, emotions). We discuss each of these components in greater detail below. Assessors should collect specifics concerning the course of NSSI behaviors over time. For example, has the individual’s NSSI taken a chronic course with frequent and repeated instances over several years, or a more acute, infrequent course with limited occurrences over recent weeks or months? Has the self-​ injury been fairly stable across time, or has it fluctuated in frequency, severity, and method since its onset? The assessor should also determine whether the NSSI occurs on a regular basis, or if NSSI occurs more sporadically in response to specific life events and stressors, as well as the factors associated with the stability or instability of the behavior. Further, it is important to identify the client’s typical NSSI behavioral pattern (e.g., method, frequency, duration, severity), as well as the most severe lifetime episode. Understanding the details of the client’s urges to self-​injure is also essential. When did the client begin having urges? How often do urges occur? What prompts urges? How intense are the urges? What contexts prompt more/​less, stronger/​weaker urges? Further, an assessor must consider how much time typically occurs between urge and action (e.g., seconds, minutes, hours), as well as the degree to which the client is able to delay or resist urges. The client’s treatment history also informs case conceptualization and treatment planning. If the client has a past treatment history for NSSI, assessors should inquire about the types of intervention received, what was helpful/​ unhelpful about each intervention, and who provided each intervention. Family history also provides clinically relevant biopsychosocial information. Thus, the assessor should inquire about current or past NSSI (and other mental health concerns) that occurred in the nuclear and extended family. Collectively, this historical information helps assessing risk, severity, and safety, as well as treatment planning.

Comprehensive Assessment of NSSI  129

Determining Severity of NSSI It is important to determine the severity of the client’s NSSI behaviors. Although all NSSI is potentially cause for concern, not all NSSI is equally severe. Therefore, determining severity is critical in understanding risk and the appropriate level of intervention necessary for the individual. Determining severity of NSSI involves an assessment of frequency, method, damage to tissue, location of the wound, and tolerance of the injury.

Frequency Frequency of urges and behaviors can vary greatly from person to person as well as within an individual over the course of one’s life. Cases involving more frequent self-​injury are higher risk and more severe. More frequent NSSI increases risk for several physical and mental health consequences, including death. While there are no formal standards in determining severity by frequency, Whitlock and colleagues (2008) provide helpful cut-​offs. Individuals who reported less than 11 lifetime NSSI incidents and who tended to use only one, low tissue damage NSSI method were categorized as “superficial self-​injurers.”Those with a limited number of lifetime NSSI instances (i.e., less than 11), but who used three or fewer methods, with at least one that leads to moderate to high level of tissue damage, were classified as “moderate severity self-​injurers.” Finally, those who reported moderate to high-​frequency lifetime NSSI incidents and more than three methods, with at least one dangerous method that leads to a high degree of tissue damage, were classified as “high severity self-​injurers.”

Method As noted by Whitlock and colleagues (2008), it is not enough to just understand the frequency of NSSI, but also the number of different NSSI methods an individual has used over their lifetime. There are an infinite number of NSSI methods. While skin-​cutting is the most commonly reported method (Klonsky, 2007), other common methods include burning, scratching, skin-​puncturing, hitting oneself, and ingesting poisonous substances. Notably, many individuals utilize multiple NSSI methods (Nock & Favazza, 2009). When inquiring about methods used, we recommend asking open-​ended questions in addition to asking about specific methods (e.g., “In what other ways have you deliberately harmed yourself without the intent of ending your life?”), as this allows one to potentially detect unconventional methods of NSSI. Some methods (e.g., skin-​cutting with razors, burning) can lead to substantial tissue damage and increased risk of severe injury or death compared to others (e.g., scratching with fingernails). Further, the number of NSSI methods utilized is indicative of risk, as research suggests that a greater number of NSSI methods

130  Gregory J. Lengel and Denise Styer

is predictive of suicide behavior (Victor & Klonsky, 2014). Thus, the use of multiple methods should signal heightened clinical concern. Similarly, the tools utilized to injure can also indicate severity. Are specific tools used to injure, or does the client injure with whatever is available? Does the client have access to and capability of using these tools? For individuals who injure with whatever tools are available (e.g., sharp objects, corners of tables, hot objects to burn skin), careful consideration should be made to identify ways of keeping the client safe. Additionally, it is significant to assess the location that the individual stores their tools (e.g., kept on person, hidden in a room), as well as whether the individual uses specific tools only (e.g., razor blade, knife, pin), or if they are inclined to use whatever they can find to harm themselves (e.g., sharp corner of a desk, pencil). It is important to note that methods, in and of themselves, are not a sufficient means of determining severity because there is great variability in tissue damage within and across methods. For example, skin-​cutting can range from superficial scratches that immediately scab over to deep wounds that require urgent medical intervention. Therefore, a determination must be made regarding how and to what degree the individual utilizes a particular method. Another variable to consider when evaluating the severity of the behavior is if and how one’s NSSI methods have changed since initial onset. A gradual escalation in the severity of the method utilized could be indicative of higher risk, particularly a growing tolerance for pain or a decreasing reinforcement from the behavior. For instance, an escalation from superficially scratching oneself with a fingernail to deeply cutting oneself with a razor can be indicative of a worsening course.

Tissue Damage The amount and degree of tissue damage is perhaps more significant than the specific methods utilized. NSSI can lead to significant or permanent tissue damage, require first aid, or could potentially place the individual at risk of accidental death (e.g., cutting near major arteries). Accordingly, it is critical to determine the extent to which tissue damage has occurred. Is the injury localized to a single area of the body, or to several areas? How many cuts, burns, etc. are present? How medically severe are the injuries? Although assessors with mental health training can assess the severity of damage from NSSI, it is preferable that a trained medical provider, such as a physician or nurse, perform this assessment. The stages of wound healing and scars can provide insight to the chronicity, severity, and course of NSSI behavior. Wounds that are in various stages of healing, reopened and persistent wounds, and appearance of scars point towards significant, ongoing, self-​injurious behavior. A lack of scars could indicate that the NSSI onset is more recent, while a lack of “fresh” wounds and bruises could indicate a lessening in frequency. The client’s need for medical treatment (e.g., emergency room visit, sutures, burn wrap) at any point as a result of self-​injurious behavior is also indicative

Comprehensive Assessment of NSSI  131

of severity of tissue damage. Similarly, it is important to determine whether the individual ever caused more damage or harm than initially intended, as one might inadvertently cause severe tissue damage or even death, despite not intending to do so. Engaging in NSSI that required medical attention or was more severe than initially intended is a cause for heightened concern.

Wound Location Individuals may injure in a variety of locations on the body. Often, NSSI is clustered on a certain part of the body (e.g., forearms, upper arms, thighs). Wounds located in places where accidental injury is uncommon or atypical, such as one’s stomach, thighs, and chest can be a sign of NSSI. It is common to see several wounds of a similar size, in a similar direction, or in a particular pattern or shape, located close together on the body (e.g., line of several small cuts along the forearm). A client might injure in a particular location for a variety of reasons. For example, NSSI in a location that is very visible (e.g., wrists, while wearing short sleeves) might indicate a desire to communicate their NSSI, while injuries on the upper extremities or other areas regularly covered by clothing might indicate a desire to conceal NSSI behavior. Others may injure in particular locations or patterns for symbolic reasons (e.g., cutting breasts or genitals following sexual abuse to punish oneself). As part of an ongoing assessment, the assessor should note whether the individual changes the location of NSSI. A location change might be done for practical reasons, such as shifting from injuring on forearms or thighs to upper arms and stomach due to having to wear less-​covering dress in the summer, or it may suggest more clinically relevant changes (e.g., increased distress, severity, elevated stressors, abuse). Wound clusters, wounds parallel along the wrist, and wounds forming a design/​shape suggest more severe NSSI (Washburn et al., 2014). For example, cutting along the wrist can lead to significant blood loss or accidental death. Further, NSSI on the face, eyes, breasts (in females), and genitals suggest elevated distress and potential need for emergency intervention (Walsh, 2012). As noted above, clients may attempt to cover up and hide wounds or signs of NSSI. As such, assessors should be mindful of attempts to hide NSSI, such as wearing covering clothing and jewelry, especially during times where it is inappropriate (e.g., long sleeves in the summer), refusing to wear certain items of clothing (e.g., shorts, bathing suit in summer), avoiding activities or situations which would require evidence of injury to be visible (e.g., swimming, doctor’s appointments, disrobing in view of others).

Tolerance Whether and how the NSSI behavior has changed in its ability to serve a particular function or purpose for the individual should be assessed. For instance,

132  Gregory J. Lengel and Denise Styer

has a tolerance developed for the NSSI behavior? Does it take more frequent, intense, or severe NSSI behavior to obtain the desired function since onset of the behavior? Increased tolerance could lead to a progression to more severe means of injuring, which in turn, increases risk.

Functions of NSSI Determining the functions of NSSI is essential to a comprehensive assessment. NSSI can serve several functions, and assessment of these functions can help intervention planning by highlighting the reinforcing contingencies maintaining the behavior, as well as the core, underlying problems associated with the NSSI. This information can subsequently be used to develop intervention plans so that the client can develop alternative adaptive behaviors and skills to replace NSSI. For example, if an individual engages in NSSI to relieve negative affect, a clinician can provide the client with healthy emotion regulation strategies to use when experiencing negative affect. NSSI functions are often categorized into two groups: social/​interpersonal and self-​ focused/​ intrapersonal. Examples of social/​ interpersonal functions include marking distress, revenge, demonstrating toughness, creating interpersonal boundaries, and interpersonal influence. Examples of self-​focused/​intrapersonal functions include affect regulation, self-​punishment, anti-​dissociation, anti-​ suicide, and injuring for purposes of self-​ care (Klonsky, Glenn, Styer, Olino, & Washburn, 2015). Notably, research indicates that intrapersonal NSSI functions are more strongly correlated with clinical severity indicators, such as suicide ideation (e.g.,Victor et al., 2015). Affect regulation is one of the most widely researched and reported NSSI functions. Indeed, clinicians will find that self-​injurers often engage in NSSI to reduce negative affect. Klonsky (2007) reviewed 18 studies that examined NSSI functions and found that self-​injurers frequently reported a strong association between NSSI and negative affect reduction, and suggested that negative affect frequently precedes self-​injurious behavior and a reduction in negative affect is found following NSSI.

Contextual Factors Beyond the form and function of the self-​injurious behaviors, it is essential to identify the environmental, emotional, cognitive, and biological contexts in which NSSI urges and behaviors occur. Accordingly, physical locations in which the NSSI behavior takes place (e.g., at home, in a specific room) and the reasons the client chooses to injure in those environments are important (e.g., privacy) to determine. Whether or not the client is alone when she or he self-​injures is also important, as this can have significant implications on severity and risk. Notably, people who injure alone are at elevated risk for engaging in suicidal self-​injury (Glenn & Klonsky, 2009). Additional environmental factors include,

Comprehensive Assessment of NSSI  133

but are not limited to, life stressors associated with NSSI, socioeconomic status (SES), employment (e.g., stressful work environment, recently unemployed), and academic stressors and performance. In terms of emotional and cognitive contextual factors, the assessor should carefully examine the feelings and cognitions that often accompany NSSI. For example, what are the specific emotions that are associated with or precede NSSI? Identifying specific emotions that the individual finds intolerable or difficult to regulate can help inform one’s treatment plan. Similarly, what are the automatic thoughts that occur prior to, during, and after NSSI occurs? NSSI is often associated with maladaptive cognitions, such as self-​defeating thoughts (e.g., “I’m worthless”) that can come before, during, and after the behaviors. Identification of these maladaptive cognitions can help provide context to what contributes to the development and maintenance of these maladaptive behaviors as well as inform intervention strategies. Biological contextual factors and vulnerabilities are also relevant in NSSI. For example, lack of sleep can increase emotion dysregulation and impulsivity (e.g., Anderson & Platten, 2011; Simon et al., 2015), potentially increasing susceptibility to NSSI. Additionally, intoxicating substances might play a significant role in self-​injury. For example, does the client engage in NSSI solely when under the influence of drugs or alcohol? Is the NSSI more severe under the influence? Does the person take substances to reduce pain? Is a substance used to build up the “courage” or reduce inhibitions to engage in the behavior? Do substances moderate the method, frequency, or severity of the NSSI? Similarly, if the individual is prescribed a medication, are they adherent to the prescription?

Antecedents and Consequences Functional analysis of the antecedents and consequences of self-​ injurious behaviors can be very effective in understanding the aforementioned environmental, biological, emotional, and cognitive contextual factors that precede and follow NSSI urges and behaviors. Some important factors to consider in a functional analysis include the location/​setting the individual was in when he or she experienced the urge to injure, what was occurring at the time, who the individual was with, the emotions the individual was feeling, and the specific automatic thoughts (e.g., “I’m worthless”). Careful examination of these contextual antecedents can provide valuable insight into what leads to the NSSI and may help identify key patterns which can be utilized in treatment planning. Equally significant are the positive and negative, as well as the short-​and long-​ term, consequences of the NSSI behavior. Short-​term positive consequences (e.g., “feeling better”) provide useful information about potential functions and reinforcing properties of the behavior (e.g., affect regulation), while short-​ term negative consequences (e.g., pain, social rejection, embarrassment, having to hide wounds) can provide insight regarding what might inhibit one from engaging in the behavior.

134  Gregory J. Lengel and Denise Styer

The experience of pain as a result of NSSI is relevant. Pain can act as a deterrent; however, some may find it reinforcing (e.g., distraction, wanting to “feel” something). Others may report not experiencing pain or a reduction in pain over the course of their NSSI behavior. Notably, individuals who experience less pain might be at increased risk of more severe NSSI, tissue damage, as well as death (Nock, Joiner, Gordon, Lloyd-​Richardson, & Prinstein et al., 2006). The long-​term consequences of NSSI are also important to assess. When prompted, self-​injurers are often able to identify potential negative long-​term consequences (e.g., scarring, dependence); however, self-​ injurers frequently overlook these consequences, especially when experiencing urges or engaging in NSSI. If individuals were more mindful of these long-​term outcomes, they might be more hesitant to act on urges and be more inspired to adopt healthier means of coping. Collectively, identification of both short-​and long-​ term consequences is clinically useful, as this practice can identify potential alternative coping skills (e.g., relaxation to reduce negative affect), and provide motivation for behavior change. The consequences of NSSI can affect all domains of living (e.g., personal, social, academic, occupational). For example, chronic NSSI can lead to intrapersonal dysfunction such as decreased self-​esteem, heightened intolerance for uncomfortable emotions, increased risk of suicide, reduced self-​confidence, and several comorbid disorders. Interpersonally, NSSI can negatively impact one’s social, academic, and occupational functioning. However, it is important to note that one may experience a sense of community with other self-​injurers.

Social Context While not everyone who self-​injures does so to fulfill a social function, research has demonstrated that social factors often play a significant role in NSSI. For example, Heath et al. (2009) examined retrospective reports of social influences on NSSI behaviors. Results showed that, overall, 65.5% of the sample reported that they had “social motivations” for engaging in NSSI. In addition, 65% reported speaking to their friends about NSSI, 58.8% reported that a friend had engaged in NSSI first, and 17.4% reported having engaged in NSSI in front of friends. Finally, social support was lower for those who had an NSSI history, although social support was not related to the frequency of NSSI behavior. Social contextual factors include, but are not limited to, one’s level of perceived social support, satisfaction with social relationships, relationships with family members and peers, and romantic relationships (e.g., relationship problems, recent break up). Additionally, NSSI is linked to peer influence and social contagion (Jarvi et al., 2013). Thus, the assessor should determine if there is NSSI among other family members and peers, as well as family members’ and peers’ perspectives of NSSI. Has the client informed others of his or her behavior? Further, what is the relationship between the client’s internet use and NSSI? For example, some clients might utilize the internet to communicate with and

Comprehensive Assessment of NSSI  135

receive support from other self-​injurers, or visit websites, blogs, or other social media that support NSSI.

Risk Factors and Comorbidities Several risk factors have been identified for NSSI. For example, childhood and adolescent risk factors are associated with NSSI onset and severity, such as trauma (e.g., physical and sexual abuse), neglect, separation, loss, and attachment quality (Gratz, 2003). In addition to childhood experiences, sociodemographic and psychological risk factors have been identified (Fliege, Grimm, & Klapp, 2009). Age and gender may also be important risk factors, as rates of NSSI are elevated in adolescents and young adults, as well as among women. Education and SES also appear to play a role in NSSI, as studies have found elevated risk for NSSI among adolescents with a lower-​quality education as well as single and unemployed adults (Fliege et al., 2009). Additionally, there are strong associations between NSSI and mental disorders. For example, research shows that NSSI is prominently comorbid with depressive disorders (Jacobson, Muehlenkamp, Miller, & Turner, 2008; Klonsky, Oltmanns, & Turkheimer, 2003; Nock et  al., 2006). There is also strong comorbidity between NSSI and anxiety disorders, particularly generalized anxiety disorder and posttraumatic stress disorder, eating disorders/​disordered eating behaviors, and substance use disorders (Claes,Vandereycken, & Vertommen, 2001; Deliberto & Nock, 2008; Haw, Hawton, Houston, & Townsend, 2001; Nock et al., 2006; Whitlock, Eckenrode, & Silverman, 2006). Of all mental disorders, NSSI is most often associated with borderline personality disorder (BPD). This is likely because BPD is the only DSM-​5 disorder in which NSSI is a criterion (i.e., “Recurrent suicidal behavior, gestures, or threats, or self-​mutilating behavior;” APA, 2013, p.  663), and not surprisingly, there area strong anecdotal and empirical associations between BPD and NSSI (Linehan, 1993). While the association between BPD and NSSI is significant, it is important to highlight that NSSI is not synonymous with BPD (and vice versa). For example, Glenn and Klonsky (2013) examined the extent of the overlap between the proposed DSM-​5 NSSI disorder and BPD.They found that the overlap between NSSI disorder and BPD was no greater than NSSI disorder and other clinical syndromes (e.g., anxiety disorders, mood disorders) and that NSSI disorder retained unique associations with measures of clinical impairment (emotion dysregulation, loneliness, and suicide ideation and attempts) after controlling for BPD. General personality traits may also play a significant role in the development and maintenance of NSSI behavior. For example, individuals with a history of NSSI report elevated neuroticism, and to a lesser extent, openness, as well as low conscientiousness (Mullins-​Sweatt, Lengel, & Grant, 2013). Impulsivity, particularly negative urgency (i.e., tendency to act rashly when under conditions of negative affect; Whiteside & Lynam, 2001), is often significantly elevated among

136  Gregory J. Lengel and Denise Styer

individuals who self-​injure (Lengel, DeShong, & Mullins-Sweatt, 2016; Mullins-​ Sweatt et  al., 2013). Assessing for personality disorders as well as dimensional personality traits in clients with NSSI can be useful for case conceptualization and treatment planning.

Other Constructs of Interest Suicide Suicide is a significant risk among those who self-​injure. In fact, with the exception of suicide ideation, NSSI is the strongest predictor of suicide attempt  –​ more so than past suicide attempts, psychopathology, age, gender, and SES (Klonsky et al., 2013; Prinstein et al., 2008; Wilkinson et al., 2011). In addition, suicidal intent may emerge from behaviors that were initially nonsuicidal in nature. Thus, it is critical to routinely assess for suicidal behavior in addition to NSSI, being especially conscientious about distinguishing between suicidal self-​ injury and NSSI. Motivation to Change In clinical settings, it is significant to determine the client’s motivation to change as this information can help determine the appropriate level of care and treatment approach. The stages of change model, otherwise known as the transtheoretical model (Prochaska & DiClemente, 1992), is a helpful framework from which to assess current willingness to engage in behavior change. For example, if the client is in the precontemplation (i.e., does not intend on changing in the foreseeable future) or contemplation stage (i.e., is ambivalent, but has some intention on changing the behavior in foreseeable future), further assessment might be warranted to determine what might be preventing the individual from changing (e.g., lack of confidence, unawareness of negative short-​/​ long-​term consequences of behavior, lack of support). Coping Skills In the long term, NSSI is ineffective, dangerous, and reduces one’s ability to manage and tolerate uncomfortable emotions; however, self-​injurers report significant short-​term reinforcement following the behavior (e.g., rapid reduction in negative affect; Klonsky, 2007). Replacing NSSI and any other maladaptive coping behaviors with more effective, healthy coping skills (e.g., relaxation, mindfulness, deep breathing, distress tolerance) is often a primary treatment goal. Accordingly, assessment of which alternative coping skills the individual has learned or attempted in the past, along with what led to the success and failure of utilizing these skills (e.g., knowledge and practice of the skill, access to utilizing the skills and alternative skills) can be beneficial for treatment planning and help one build upon past successes and avoid past pitfalls.

Comprehensive Assessment of NSSI  137

Strengths Client strengths are often overlooked in clinical assessment. It is important, however, to identify and reinforce these strengths. Examining and highlighting a client’s strengths can also help build rapport. In addition, identifying strengths might help instill hope, highlight areas of resilience and coping on which to build, and can potentially help reduce NSSI. Potential strengths include, but are not limited to, intelligence, creativity, hobbies and activities, scholastic and professional achievement, social skills, relational supports, and religious/​spiritual beliefs.

NSSI Assessment Frameworks As noted above, many clinicians have limited time to assess and treat clients. Thus, a framework from which to operate can help ensure that assessment of critical variables is conducted with efficiency. The following frameworks utilize acronyms to help clinicians remember the key components to their assessment and can be useful in NSSI screening. HIRE Model Buser and Buser’s (2013) HIRE model allows for an efficient informal assessment of NSSI, which can then be followed up with a more comprehensive evaluation. Accordingly, this model is especially helpful in primary care, emergency, and other settings where there is limited time to complete assessment and make clinical decisions regarding the necessary level of care. The components of the HIRE model include assessment of History, Interest in change, Reasons behind behavior, and Exposure to risk. History focuses on the frequency and methods engaged in by the client, with primary attention to behaviors that occurred in the past year. The interest in change component focuses on one’s motivation to reduce or eliminate NSSI behavior as well as on the negative outcomes of the behavior. This serves multiple purposes. First, knowledge of the client’s current motivation to change is important for making clinical decisions and treatment planning. Second, discussion and awareness of the negative consequences of NSSI might increase one’s motivation to change. The reasons behind behavior component examines the inter-​and intrapersonal functions of the NSSI behavior(s). As discussed above, understanding of the functions of NSSI aids in treatment planning because functions help clarify what potentially is reinforcing the behavior, as well as allowing the clinician to recommend healthy alternative coping skills that can serve a similar function as NSSI. Finally, exposure to risk addresses the severity and addictive features of the behavior(s), one’s sense of control, and suicide ideation. As noted above, NSSI is one of the strongest risk factors for suicide. Thus, it is critical to determine suicide risk when assessing for NSSI.

138  Gregory J. Lengel and Denise Styer

STOPS FIRE Model Kerr, Muehlenkamp, and Turner’s (2010) STOPS FIRE model is another framework for efficient assessment of critical NSSI variables, designed, in part, to help guide physicians in family medicine and primary care settings. The first component of this model is suicidal ideations. As discussed above, one should inquire whether the client has thought about ending his or her life when engaging in self-​injury as well as when they do not self-​injure. Next, the clinician examines the types of NSSI in which the client engages. High-​r isk clients are identified as engaging in multiple types (≥ 3 methods) of NSSI. Onset of the NSSI behavior is also assessed. Higher-​r isk clients tend to have an early/​childhood onset as well as an extended duration of behavior (≥ 6 months). Next, the clinician assesses the place/​location of the injury. Those that injure the genitals, breasts, and face are of higher risk and may need a higher level of care. Severity is assessed by determining whether behavior(s) have led to bleeding, bruising, scarring, or the need to seek medical attention following the injury. Individuals who require hospitalization or sutures as well as neglecting care of or reopening their wounds are higher-​r isk. FIRE refers to the function, intensity, and frequency of the behavior. Accordingly, the clinician assesses the functions of each NSSI behavior and how the individual feels before and after the behavior as well as whether it would be helpful to stop the specific NSSI behavior. Higher-​r isk clients are identified by functions that are related to suicide (e.g., reducing suicidal thoughts). Next, intensity of urges is assessed by asking the client to rate his or her urges to injure in a typical day from 0 to 100 (≥  70 indicates higher risk). Repetition of the behavior is assessed by approximating the frequency for NSSI behavior (11–​50 times = moderate risk, ≥ 50 times = high risk). Finally, episodic frequency refers to the number of times one engages in a specific NSSI behavior per day and per week.Those who engage in NSSI multiple times per week and have ≥ 5 wounds per episode are identified as high-​r isk.

NSSI Assessment Instruments The following section is not intended to be a comprehensive list of NSSI interviews and self-​report measures. Rather, the present chapter will highlight some of the prominent NSSI measures that can be utilized as part of a comprehensive assessment. Structured Interviews Self-​Injurious Thoughts and Behaviors Interview (SITBI) The SITBI (Nock, Holmberg, Photos, & Michel, 2007) is a well-​validated, reliable, 169-​item structured interview that is often used in adolescent and young adult populations. The SITBI was designed to be a comprehensive measure

Comprehensive Assessment of NSSI  139

of suicidal and nonsuicidal self-​injurious thoughts and behaviors (i.e., suicidal ideation, suicide plans, suicide gestures, suicide attempts, and NSSI). For each self-​injurious thought and behavior, the SITBI assesses onset, methods, severity, functions, antecedents, experience of pain, use of substances in relation to self-​ injurious thoughts and behaviors, impulsivity, peer influences, and future probability. The SITBI can be administered as a self-​or parent report, in a variety of clinical settings, and takes approximately 3–​15 minutes to complete. Further, the SITBI has strong interrater and test–​retest reliability as well as strong construct validity. Suicide Attempt Self-​Injury Interview (SASII) The SASII (Linehan, Comtois, Brown, Heard, & Wagner, 2006) is a 42-​item (plus additional follow-​up items) formal structured interview that assesses several forms of self-​inflicted injury and distinguishes between suicidal and nonsuicidal self-​injury. The SASII is extremely thorough, and examines key factors related to self-​harm, such as history, method, lethality, intent, communication of suicide intent, impulsivity and probability of intervention, level of medical treatment required and received, precipitating events, context (environmental, affective, cognitive), functions, and consequences. Items vary in their format (e.g., open-​ ended questions, Likert scales, yes/​no). The primary benefits of the SASII are that it is quite comprehensive and it has very strong reliability and validity in clinical samples; however, it can also be very time-​consuming depending on the number of self-​injurious behaviors endorsed. Self-​R eport Measures Functional Assessment of Self-​Mutilative Behavior (FASM) The FASM (Lloyd, Kelley, & Hope, 1997) is a well-​validated self-​report measure of the frequency, methods, and functions of NSSI behaviors. Participants are first asked to rate history as well as lifetime and past-​year frequency of 11 unique NSSI behaviors. There are 22 items which ask one to report how often she or he engages in NSSI for a particular reason (e.g., “to stop bad feelings,” “to get control of a situation,” “to relieve feeling numb or empty,” “to get help”) using a four-​point Likert scale (0 = never to 3 = often). The FASM has strong psychometric properties (e.g., Guertin, Lloyd-​Richardson, Spirito, Donaldson, & Boergers, 2001; Lloyd et al., 1997) and can be used for both clinical and research purposes. Inventory of Statements About Self-​Injury (ISAS) The ISAS (Klonsky & Glenn, 2009) is another self-​report measure of the features and functions of NSSI. This measure has two sections. The first asks participants

140  Gregory J. Lengel and Denise Styer

to report the form and frequency of 12 NSSI behaviors (plus an “other” option), as well as to indicate the “main” form of self-​injury. Descriptive features of NSSI are also assessed (e.g., date of onset and most recent harm, experience of physical pain, the tendency to self-​injure when alone, time between urge and action, desire to stop injuring). The second section assesses 13 potential functions of NSSI that have been proposed in the empirical and theoretical literature (e.g., affect regulation, self-​punishment, interpersonal). Research has shown a robust and theoretically sound factor structure. Deliberate Self-​Harm Inventory (DSHI) The DSHI (Gratz, 2001) is a 17-​item self-​report measure that examines behavioral aspects of NSSI.The DSHI assesses history of NSSI across 16 specific NSSI behaviors (plus an “other” option). Specifically, the measure asks participants to report age of onset, frequency, most recent engagement in the behavior, and whether the behavior has led to hospitalization or medical treatment.The DSHI is quick to administer and has high internal consistency (α = .82), test–​retest reliability (r = .92), and adequate validity (Gratz, 2001), and is useful in both clinical and research settings. Self-​Harm Behavior Questionnaire (SHBQ) The SHBQ (Gutierrez, Osman, Barrios, & Kopper, 2001) is a self-​report inventory developed to be a measure that balances the depth of quantitative and qualitative information that is typically obtained from a clinical interview with the efficiency and ease of administration associated with self-​report questionnaires. The SHBQ consists of four sections:  (A) intentional NSSI, (B) suicide attempts, (C) suicide threats, and (D) suicide ideation. Each section contains follow-​up questions that assess variables such as the history, frequency, intent, severity, and disclosure of the behavior(s). The SHBQ has been validated with undergraduate populations and can be used in both clinical and research settings. Self-​Harm Inventory (SHI) The SHI (Sansone, Wiederman, & Sansone, 1998) was developed as a self-​ report screening measure for NSSI behavior and BPD. The measure is brief, with 22 items which dichotomously (yes/​no) assess whether one has a ­history of 22 unique direct (e.g., “cut yourself on purpose”) and indirect (e.g., “driven recklessly on purpose”) self-​ harming behaviors. The SHI has a number of strengths, including, but not limited to, strong validation (e.g., Sansone et  al., 1998), assessment of both direct and indirect self-​destructive behaviors, ease of administration, and short administration time. However, the measure is limited as it does not assess the history, functions, and severity of these behaviors.

Comprehensive Assessment of NSSI  141

Self-​Injury Questionnaire (SIQ) The SIQ (Santa Mina et al., 2006) is a brief, 30-​item self-​report measure of “the frequency, type and functions of self-​harm behaviors and their associations with histories of childhood trauma” (p. 222). The SIQ assesses self-​ harm behavior across four domains:  body alterations, indirect self-​harm, failure to care for self, and overt self-​injury, which makes it useful for assessing NSSI, as well as other maladaptive behaviors beyond the traditional NSSI definition. Santa Mina et  al. (2006) validated the measure using a clinical sample of 83 individuals who had engaged in a “self-​harm episode” (p. 223). A principle components analysis yielded a five-​f actor solution: affect regulation, management of dissociation, suicide, communication, and stimulation. Additionally, the SIQ scales have adequate internal consistency and good construct validity. Alexian Brothers Assessment of Self-​Injury (ABASI) and Alexian Brothers Urge to Self-​Injure (ABUSI) Scale The ABASI (Washburn, Potthoff, Juzwin, & Styer, 2015) is a self-​report measure designed to assess clinical severity, history, frequency, expectations, and treatment of NSSI behavior. The measure was created as an assessment for the proposed DSM-​5 NSSI disorder and can be utilized to identify those who meet criteria for NSSI disorder, and has been validated with clinical samples. The ABASI asks participants to report the number of days, times, and age of onset of 21 unique NSSI behaviors, expectations of NSSI behavior, interpersonal difficulties, negative emotions and thoughts, preoccupation with NSSI prior to engaging in the behavior, and frequent thoughts of NSSI. Additionally, the measure asks about locations of NSSI, history of sexual, physical, and emotional/​verbal abuse and suicide attempts. The ABUSI (Washburn, Juzwin, Styer, & Aldridge, 2010) is a brief, five-​item self-​report measure of one’s urge to engage in NSSI behavior. The measure asks participants to report how often they thought about injuring or how to injure, strengths of urges, time spent thinking about NSSI, difficulty resisting urges, and overall urge to injure within the past week. The ABUSI has demonstrated adequate psychometric properties in clinical samples and can be used clinically to measure severity and outcome. Ottawa Self-​Injury Inventory (OSI) The OSI (Cloutier & Nixon, 2003) is a self-​report measure designed to comprehensively assess the functions and addictive properties of 17 NSSI methods. The OSI includes items that examine the history, frequency, ­location, method, and severity of the self-​injurious behavior(s), urges, and context (e.g., substance use, communicating NSSI). There is also a scale that assesses four functions of

142  Gregory J. Lengel and Denise Styer

NSSI (i.e., Internal Emotion Regulation, External Emotion Regulation, Social Influence, and Sensation-​ Seeking), as well as a scale that assesses Addictive Features. The OSI also includes items related to suicidal thoughts, past treatment, and alternative methods of coping.

Cognitive-​B ehavioral Tracking Methods Ideally, NSSI assessment should be an ongoing and active process that utilizes techniques beyond self-​report inventories and clinical interviews. While the aforementioned assessment frameworks and tools can be utilized beyond initial assessment, they rely on retrospective self-​report. Retrospective self-​report is problematic because clients may lack insight into, or simply may be unable to accurately recall the details surrounding their behaviors. Accordingly, cognitive-​behavioral tracking techniques can be very useful in both clinical and research settings as they can provide more accurate, in-​the-​moment insights into one’s NSSI behavior. Chain Analysis Chain analysis is a tool utilized in many behavior therapies, including dialectical behavior therapy (DBT) and can be usefully applied to NSSI assessment. Briefly, chain analysis involves describing the problem behavior (e.g., NSSI) in specific detailed terms, identifying the prompting event (including personal and environmental vulnerabilities) as well as the chain of events from the prompting event to the problem behavior (i.e., “chains”) in as much detail as possible. In addition, one identifies the consequences of the behavior. A more detailed description of behavioral chain analysis can be found elsewhere (see Linehan, 1993). Chain analysis can be particularly helpful when a client lacks insight into his or her NSSI behaviors. Chain analysis can help one identify the thoughts, emotions, settings, and events that trigger NSSI, and examination of the behavioral consequences can help identify the functions of the behavior. In addition, identifying the chain of events that led to NSSI can help one be more mindful of the complex series of events that leads up to NSSI, as well as identify where healthier and appropriate coping skills can be implemented to prevent future NSSI. Thus, chain analysis is helpful in both clinical assessment and intervention. Self-​I njury Tracking Logs and Ecological Momentary Assessment Using behavioral tracking logs is also an effective way to assess NSSI behavior. One method is using a weekly monitoring form which allows one to track NSSI behaviors, urges, and covariates across time and to monitor progress. Unfortunately, retrospective reporting can be subject to error and bias. Tracking key information regarding NSSI behavior (e.g., frequency, duration, precipitating

Comprehensive Assessment of NSSI  143

events, thoughts, emotions, consequences) in the moment can potentially provide more accurate and detailed insight into the behavior. Therefore, utilizing a tracking log for the client to utilize in the moment to monitor thoughts, emotions, and behaviors related to NSSI can be a useful tool for clients, clinicians, and researchers. Ecological momentary assessment (EMA) is an assessment technique that allows the capture of real-​time data of one’s thoughts, emotions, and behaviors in their natural environment, and is increasingly being utilized in the empirical literature to examine NSSI phenomenology. As smartphones and other portable technology become ubiquitous in society, clinicians and researchers would be wise to utilize these devices and mobile applications (apps) to aid in NSSI assessment. There is a growing trend of mental health-​oriented apps utilized for clinical assessment and intervention purposes (e.g., tracking behaviors, CBT thought logs, daily diaries). Apps designed to assess NSSI, using real-​time EMA techniques can offer clinicians and researchers a wealth of clinically useful information (see Lederer & Baranyi, 2015, for a discussion of recently developed NSSI mobile assessment and intervention apps).

Demeanor and Establishing Rapport Before we conclude, a brief discussion about the assessor demeanor and establishing rapport is warranted. As with the assessment of any sensitive construct, the assessor’s confidence and demeanor can play a significant role in the quantity and quality of the information obtained. Clients may be reluctant to disclose their NSSI with others, including professionals, for a variety of reasons (e.g., fear of judgment, negative reactions, personal guilt). Individuals are more likely to disclose and discuss their NSSI history openly and honestly when they are in an environment that fosters strong rapport and trust. However, establishing this rapport can be quite challenging. There are no steadfast rules for establishing rapport or what constitutes a proper demeanor; however, there are some suggested strategies. For example, NSSI assessors should be well-​ prepared and exhibit a calm, confident, accepting demeanor.The assessor should not express approval of or support for the client’s self-​injurious behavior; however, the assessor should be validating of the client’s distress and their use of NSSI as a coping mechanism. According to Dr. Barry Walsh (2012), there are dangers in being too accepting/​interested as well as too negative in one’s demeanor. Too much reassurance, interest, or acceptance can inadvertently reinforce and escalate the NSSI behavior. However, a style that suggests disapproval or negativity about NSSI can hinder rapport. Therefore, Dr. Walsh (2012) recommends that assessors should have a “low-​key, dispassionate demeanor” (p. 84) –​meaning that one should avoid emotionally reactive responses, overly nurturing responses, and condemnation to avoid adding affect into the situation and to avoid reinforcing maladaptive behaviors.

144  Gregory J. Lengel and Denise Styer

Rapport-​building can be especially challenging with adolescents. Adolescents can be quite reluctant to disclose details regarding sensitive behaviors, and it is common for them to worry about the repercussions of disclosing NSSI to parents/​guardians and providers (e.g., loss of privileges, hospitalization). Although demeanor and rapport are equally essential with teens, assessors must also consider rapport and alliance with parents and guardians. Early in the assessment process, assessors ought to discuss and clarify expectations for the assessment, confidentiality, disclosure, and privacy with the teens and parents/​guardians. Ideally, this is a collaborative process, with all parties present and contributing. In some cases, it is helpful to have parents/​guardians in the room during the assessment process. Assessors should also meet with the adolescent alone at some point, as this can help foster rapport as well as provide the teen a safe environment to disclose information that they might not have been comfortable disclosing with others in the room. Privacy is another area of importance and concern. Due to the risks associated with NSSI and concern for safety, we believe there is a time and place for privacy breaches. Such privacy breaches might include discussions of parental/​guardian monitoring of the child’s social media accounts, computer, cell phone, journals/​ diaries, and other communication means. As part of an ongoing assessment of behavior, the monitoring of communications and media use provides insight into the client’s NSSI behaviors and urges, as well as potential social reinforcing factors (e.g., sharing pictures of self-​injury). Room checks can also be an important part of adolescent NSSI assessment. A  sweep of the home can be particularly useful (e.g., going through everything in the room to locate and remove all items that could be used for NSSI). Expectations for these breaches of privacy should be discussed with the adolescent early in the assessment process, particularly because it will likely influence rapport and alliance. Notably, one area of privacy that is strongly discouraged is body checks. Parents/​guardians are not recommended to do body checks on their child; instead, we strongly recommend that this be done by a medical professional.

Conclusion Despite the challenges and complexity involved, clinicians and researchers should aim to conduct comprehensive NSSI assessments, whenever possible. Similarly, NSSI assessment should ideally be a continuous process during treatment, as NSSI thoughts, behaviors, and urges can change often over time. Several techniques and tools are available to aid assessors, although establishing strong rapport and using an appropriate demeanor contribute to the assessment’s overall effectiveness. Ultimately, one’s confidence and success as an assessor relies on thorough understanding of the many variables involved in, and associated with, NSSI. Therefore, it is critical that the field continues to understand and explore NSSI as a construct as well as develop and refine assessment tools and techniques. Finally, clinicians will benefit from staying current with this growing literature and modifying their assessment of NSSI in response.

Comprehensive Assessment of NSSI  145

References American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders, 5th edition: DSM-​5. Washington, DC: American Psychiatric Publishing. Anderson, C., & Platten, C. R. (2011). Sleep deprivation lowers inhibition and enhances impulsivity to negative stimuli. Behavioral Brain Research, 35, 463–​466. Buser,T. J. & Buser, J. K. (2013).The HIRE Model: A tool for the informal assessment of nonsuicidal self-​injury. Journal of Mental Health Counseling, 35, 262–​281. Claes, L.,Vandereycken, W., & Vertommen, H. (2001). Self-​injurious behaviors in eating-​ disordered patients. Eating Behaviors, 2(3), 263–​272. Cloutier, P. F., & Nixon, M. K. (2003). The Ottawa Self-​Injury Inventory: A preliminary evaluation. Abstracts to the 12th International Congress European Society for Child and Adolescent Psychiatry. European Child & Adolescent Psychiatry, 12(Suppl. 1), 1–​94. Deliberto, T. L., & Nock, M. K. (2008). An exploratory study of correlates, onset, and offset of non-​suicidal self-​injury. Archives of Suicide Research, 12, 219–​231. Fliege, H., Lee, J., Grimm, A., & Klapp, B. (2009). Risk factors and correlates of deliberate self-​harm behavior: A systematic review. Journal of Psychometric Research, 66, 477–​493. Glenn, C.  R. & Klonsky, D.  E. (2009). Social context during non-​suicidal self-​injury indicates suicide risk. Personality and Individual Differences, 46, 25–​29. Glenn, C.  R. & Klonsky, D.  E. (2013). Nonsuicidal self-​injury disorder:  An empirical investigation in adolescent psychiatric patients. Journal of Clinical Child & Adolescent Psychology, 42, 496–​507. Gratz, K.  L. (2001). Measurement of deliberate self-​harm:  Preliminary data on the deliberate self-​harm inventory. Journal of Psychopathology & Behavioral Assessment, 23, 253–​263. Gratz, K. L. (2003). Risk factors for and functions of deliberate self-​harm: An empirical and conceptual review. Clinical Psychology: Science and Practice, 10, 192–​205. Guertin, T., Lloyd-​Richardson, E., Spirito, A., Donaldson, D., & Boergers, J. (2001). Self-​mutilative behavior in adolescents who attempt suicide by overdose. Journal of the American Academy of Child and Adolescent Psychiatry, 40(9), 1062–​1069. doi:10.1097/​ 00004583-​200109000-​00015 Gutierrez, P. M., Osman, A., Barrios, F. X., & Kopper, B. A. (2001). Development and initial validation of the Self-​ Harm Behavior Questionnaire. Journal of Personality Assessment, 77, 475–​490. Haw, C., Hawton, K., Houston, K., & Townsend, E. (2001). Psychiatric and personality disorders in deliberate self-​harm patients. The British Journal of Psychiatry, 178, 48–​54. Heath, N. L., Ross, S., Toste, J. R., Charlebois, A., & Nedecheva, T. (2009). Retrospective analysis of social factors and nonsuicidal self-​injury among young adults. Canadian Journal of Behavioral Science, 41, 180–​186. Jacobson, C. M., Muehlenkamp, J. J., Miller, A. L., & Turner, E. B. (2008). Psychiatric impairment among adolescents engaging in different types of deliberate self-​harm. Journal of Clinical Child and Adolescent Psychology, 37(2), 363–​375. doi:10.1080/​ 15374410801955771 Jarvi, S., Jackson, B., Swenson, L., & Crawford, H. (2013). The impact of social contagion on non-​suicidal self-​injury: A review of the literature. Archives of Suicide Research, 17,  1–​19. Kerr, P. L., Muehlenkamp, J. J., Turner, J. M. (2010). Nonsuicidal self-​injury: A review of current research for family medicine and primary care physicians. Journal of the American Board of Family Medicine, 23, 240–​259.

146  Gregory J. Lengel and Denise Styer Klonsky, E. D. (2007). The functions of deliberate self-​injury: A review of the evidence. Clinical Psychology Review, 27, 226–​239. Klonsky, E.  D., & Glenn, C.  R. (2009). Assessing the functions of non-​suicidal self-​ injury:  Psychometric properties of the Inventory of Statements About Self-​injury (ISAS). Journal of Psychopathology and Behavioral Assessment, 31, 215–​219. Klonsky, D. E., Glenn, C. R., Styer, D. M., Olino, T. M., & Washburn, J. J. (2015). The functions of nonsuicidal self-​injury: Converging evidence for a two-​factor structure. Child and Adolescent Psychiatry and Mental Health, 9, 44. Klonsky, E. D., May, A. M., & Glenn, C. R. (2013). Relationship between nonsuicidal self-​injury and attempted suicide: Converging evidence from four samples. Journal of Abnormal Psychology, 122(1), 231–​237. doi:10.1037/​a0030278 Klonsky, E.  D., Oltmanns, T.F., Turkheimer, E. (2003). Deliberate self-​harm in a nonclinical population:  Prevalence and psychological correlates. American Journal of Psychiatry 160, 1501–​1508 Lederer, N. & Baranyi, R. (2015). Self-​injury, interrupted:  mobile technology as therapeutic accessory. Retrieved September 9, 2017 from the Cornell Research Program on Self-​ Injury and Recovery:  www.selfinjury.bctr.cornell.edu/​perch/​resources/​mobile-​ technologyfinal.pdf. Lengel, G.  J., DeShong, H.  L., & Mullins-​ Sweatt, S.  N. (2016). Impulsivity and nonsuicidal self-​ injury:  Examining the role of affect manipulation. Journal of Psychopathology and Behavioral Assessment, 38, 101–​112. Linehan, M.  M. (1993). Cognitive behavioral treatment of borderline personality disorder. New York: Guilford Press. Linehan, M.  M., Comtois, K.  A., Brown, M.  Z., Heard, H.  L., & Wagner, A. (2006). Suicide Attempt Self-​Injury Interview (SASII): Development, reliability, and validity of a scale to assess suicide attempts and intentional self-​injury. Psychological Assessment, 18, 302–​312. Lloyd, E.  E. Kelley, M.  L., & Hope, T. (1997). Self-​mutilation in a community sample of adolescents: Descriptive characteristics and provisional prevalence rates. Poster presented at the annual meeting of the Society for Behavioral Medicine, New Orleans, LA. Mullins-​Sweatt, S.N., Lengel, G.  J., & Grant, D.  M. (2013). Nonsuicidal self-​injury: The contribution of general personality functioning. Personality and Mental Health, 7,  56–​68 Nock, M. K., & Favazza, A. R. (2009). Nonsuicidal self-​injury: Definition and classification. In M. K. Nock (Ed.), Understanding nonsuicidal self-​injury (pp. 9–​18). Washington, DC: American Psychological Association. Nock, M.  K., Holmberg, E.  B., Photos, V.  I., & Michel, B.  D. (2007). Self-​Injurious Thoughts and Behaviors Interview: Development, reliability, and validity in an adolescent sample. Psychological Assessment, 19, 309–​317. Nock, M. K., Joiner, T. E., Jr., Gordon, K. H., Lloyd-​Richardson, E., & Prinstein, M. J. (2006). Non-​suicidal self-​injury among adolescents: Diagnostic correlates and relation to suicide attempts. Psychiatry Research, 144, 65–​72. Prinstein, M. J., Nock, M. K., Simon,V., Aikin, J.W., Cheah, C. S. L., & Spirito, A. (2008). Longitudinal trajectories and predictors of suicidal ideation and attempts following inpatient hospitalization. Journal of Consulting and Clinical Psychology, 76,92–​103 Prochaska, J. L., & DiClemente, C. C. (1992). Stages of change in the modification of problem behavior. In R. Eisler & P. M. Miller (Eds.), Progress in behavior modi fication. Sycamore, IL: Sycamore Publishing Company.

Comprehensive Assessment of NSSI  147 Sansone, R.  A., Wiederman, M.  W., & Sansone, L.  A. (1998). The Self-​ Harm Inventory: Development of a scale for identifying self-​destructive behaviors and borderline personality disorder. Journal of Clinical Psychology, 54, 973–​983. Santa Mina, E. E., Gallop, R., Links, P., Heslegrave, R., Pringle, D.,Wekerle, C., & Grewal, P. (2006).The self-​injury questionnaire: Evaluation of the psychometric properties in a clinical population. Journal of Psychiatric and Mental Health Nursing, 13, 221–​227. Simon, E., Oren, N., Sharon, H., Kirschner, A., Goldway, N., Okon-​Singer, H., … Hendler, T. (2015). Losing neutrality: The neural basis of impaired emotional control without sleep. Journal of Neuroscience, 35, 13194–​13205. Victor, S. E. & Klonsky, E.D. (2014). Correlates of suicide attempts among self-​injurers: A meta-​analysis. Clinical Psychology Review, 34, 282–​297. Victor, S. E., Styer, D., & Washburn, J. J. (2015). Characteristics of nonsuicidal self-​injury associated with suicidal ideation: Evidence from a clinical sample of youth. Child and Adolescent Psychiatry and Mental Health, 9,  1–​8. Walsh, B. W. (2012). Treating self-​injury: A practical guide. New York: Guilford Press. Washburn, J. J. (Ed.), Aldridge, D., Antoniewicz, T., Gebhardt, M., Juzwin, K.R., Mitckess, D., … Yourek, A.M. (2014). Self-​injury:  Simple answers to complex questions. Hoffman Estates, IL: Alexian Brothers Press. Washburn, J. J., Juzwin, K. R., Styer, D. M., & Aldridge, D. (2010). Measuring the urge to self-​injure: Preliminary data from a clinical sample. Psychiatry Research, 178, 540–​544. Washburn, J. J., Potthoff, L. M., Juzwin, K. R., & Styer, D. M. (2015). Assessing DSM-​5 nonsuicidal self-​injury disorder in a clinical sample. Psychological Assessment, 27, 31–​41. Whiteside, S. P. & Lynam, D. R. (2001). The Five Factor Model and impulsivity: Using a structural model of personality to understand impulsivity. Personality and Individual Differences, 30, 669–​689. Whitlock, J., Eckenrode, J., & Silverman, D. (2006). Self-​injurious behaviors in a college population. Pediatrics, 117, 1939–​1948. Whitlock, J., Muehlenkamp, J., & Eckenrode, J. (2008). Variation in nonsuicidal self-​ injury: Identification and features of latent classes in a college population of emerging adults. Journal of Clinical Child & Adolescent Psychology, 37, 725–​735. Wilkinson, P., Kelvin, R., Roberts, C., Dubicka, B., & Goodyer, I. (2011). Clinical and ­psychosocial predictors of suicide attempts and nonsuicidal self-​injury in the Adolescent  Depression Antidepressants and Psychotherapy Trial (ADAPT). The American Journal of Psychiatry, 168, 495–​501.

Chapter 9

Emotion Regulation Group Therapy for Nonsuicidal Self-​I njury Kim L. Gratz, Johan Bjureberg, Hanna Sahlin, and Matthew T. Tull Introduction NSSI is a clinically important health risk behavior associated with extensive impairment and high rates of co-​occurring psychopathology. Further, despite the fact that NSSI, by definition, does not involve any suicidal intent, this behavior has been found to be one of the strongest predictors of suicide attempts and death by suicide (Asarnow et al., 2011; Guan, Fox, & Prinstein, 2012;Wilkinson, Kelvin, Roberts, Dubicka, & Goodyer, 2011). Yet, despite the clinical relevance of this behavior, treatments that specifically target NSSI are scarce, and most that do exist have not been examined extensively and have limited empirical support (with many NSSI interventions supported by only one or two small trials; see, e.g., Andover, Schatten, Morris, Holman, & Miller, 2017; Glenn, Franklin, & Nock, 2015; Taylor et al., 2011). Moreover, most of these treatments have not been found to be effective for one of the clinical populations at greatest risk for NSSI: individuals with borderline personality disorder (BPD; Gunderson, 2001; Mack, 1975). Indeed, the small amount of research examining treatments for NSSI generally either includes few participants with BPD (Andover et al., 2017) or fails to find support for the utility of these treatments among those with BPD (Tyrer et al., 2004).

Emotion Regulation Group Therapy for Nonsuicidal Self-​I njury In response to the need for a brief, targeted, and empirically supported intervention for NSSI among patients with the highest rates and greatest severity of this behavior (i.e., individuals with BPD; Linehan, 1993; Zanarini, 2009), Gratz and colleagues developed an adjunctive emotion regulation group therapy (ERGT) for NSSI among women with BPD, designed to augment the usual treatment provided in the community by directly targeting both NSSI and its proposed underlying mechanism of emotion dysregulation. Specifically, based on the theory that NSSI stems from emotion dysregulation (Gratz, 2003, 2007;

Emotion Regulation Group Therapy for NSSI  149

Gratz & Gunderson, 2006), this ERGT was developed with the expectation that teaching self-​injuring women with BPD more adaptive ways of responding to and regulating their emotions would reduce the frequency of their NSSI. In particular, given evidence that many individuals who engage in NSSI struggle with and try to avoid their emotions (Chapman, Gratz, & Brown, 2006), ERGT was based on an acceptance-​based conceptualization of emotion regulation (see Gratz & Roemer, 2004) that emphasizes the functionality of emotions and problems associated with deficits in the capacity to experience the full range of emotions (Cole, Michel, & Teti, 1994; Ekman & Davidson, 1994; Thompson, 1994), as well as the paradoxical consequences of efforts to avoid or control emotions (e.g., Hayes, Luoma, Bond, Masuda, & Lillis, 2006; Salters-​Pedneault, Tull, & Roemer, 2004). This conceptualization of emotion regulation focuses broadly on adaptive ways of responding to emotions (regardless of their valence, intensity, or reactivity), including the understanding, acceptance, and effective use and modulation of emotions (Gratz & Roemer, 2004). Specifically, Gratz and Roemer (2004) conceptualize emotion regulation as a multidimensional construct involving the awareness, understanding, and acceptance of emotions; ability to control impulsive behaviors and engage in goal-​directed behaviors when experiencing negative emotions; flexible use of non-​avoidant, situationally appropriate strategies to modulate the intensity and duration of emotional responses in order to meet individual goals and situational demands; and willingness to experience negative emotions in pursuit of desired goals (see Gratz & Tull,  2010).

Treatment Description ERGT is a 14-​week, adjunctive, acceptance-​based behavioral group therapy designed to treat NSSI by directly targeting the function of this behavior and teaching self-​injuring women more adaptive ways of responding to their emotions. Specifically, this ERGT was developed to systematically target each of the dimensions of emotion regulation identified by Gratz and Roemer (2004). Given its emphasis on emotional acceptance, this treatment draws heavily from two acceptance-​based behavioral therapies, dialectical behavior therapy (Linehan, 1993) and acceptance and commitment therapy (Hayes, Strosahl, & Wilson, 1999), and emphasizes the following themes: (a) the potentially paradoxical effects of emotional avoidance, (b)  the emotion-​regulating consequences of emotional acceptance and willingness, and (c)  the importance of controlling behaviors when emotions are present, rather than controlling emotions themselves. Table 9.1 outlines the weekly content of this group therapy. Week 1 focuses on the function of NSSI, providing psychoeducation and assisting patients in identifying the functions of their own NSSI; as such, the first session is expected to target the shame often associated with this behavior. Week 2 focuses on the function of emotions. Patients are taught that emotions are evolutionarily adaptive

150  Kim L. Gratz et al. Table 9.1 Content of Emotion Regulation Group Therapy Modules Week 1 Week 2 Weeks 3–​4 Week 5 Week 6 Weeks 7–​8 Week 9 Week 10 Weeks 11–​12 Weeks 13–​14

Function of NSSI behavior Function of emotions Emotional awareness Primary vs. secondary emotions Clear vs. cloudy emotions Emotional avoidance/​unwillingness vs. emotional acceptance/​ willingness Non-​avoidant emotion regulation strategies Impulse control Valued directions Commitment to valued actions

and provide important information about the environment that can be used to guide their behavior and inform an adaptive course of action. Further, patients are taught that by acting on the information provided by their emotions in this way, they are likely to respond more effectively to their environment. This emphasis on the functionality of emotions is expected to increase emotional acceptance. Weeks 3–​ 6 focus on increasing emotional awareness and understanding. Patients are assisted in improving their ability to identify, label, and differentiate between emotional states. Specifically, patients are taught to identify the cognitive, physiological/​bodily, and behavioral components of a variety of emotional responses. For example, patients are taught to ask themselves the following questions in order to increase their awareness of an emotional response: What thoughts are associated with this emotion? What physical sensations are associated with this emotion? What action tendencies are associated with this emotion? How do I tend to act in response to this emotion? Further, patients are taught to distinguish between primary emotions (initial emotional responses to a situation) and secondary emotions (emotional reactions to these primary emotional responses), as well as to identify the negative beliefs and judgments about emotions that underlie and contribute to secondary emotional responses. Finally, the functionality of primary emotions is emphasized, and patients are encouraged to identify the information provided by their primary emotions, as well as adaptive ways of acting on this information. Weeks 7–​ 8 emphasize the experiential benefits and emotion-​ regulating consequences of emotional acceptance, as well as the potentially paradoxical long-​ term consequences of emotional avoidance. Patients are taught that emotional non-​acceptance and avoidance may amplify emotions and make the experience of emotions more distressing. A  distinction is drawn between emotional pain (which is a necessary part of life) and emotional suffering (which includes secondary emotions and failed attempts at emotional control/​avoidance). Patients are also taught that emotional acceptance results in less suffering than emotional avoidance, as it prevents the amplification of emotional arousal (despite not necessarily reducing the primary emotional response). Patients are asked to

Emotion Regulation Group Therapy for NSSI  151

actively monitor and assess the different experiential consequences of emotional willingness (an active process of being open to emotional experiences as they arise) versus emotional unwillingness. Weeks 9–​10 are the first to emphasize behavioral change, with week 9 teaching non-​avoidant strategies that may be used to modulate the intensity and/​or duration of emotions (with a distinction drawn between distraction and avoidance), and week 10 teaching basic behavioral strategies for impulse control (including consequence modification and behavioral substitution). For example, patients are taught to identify adaptive behaviors that may serve the same functions or meet the same needs as their NSSI, and to replace their NSSI with these more adaptive behaviors that serve the same function. Finally, weeks 11–​14 focus on identifying and clarifying valued directions (those things in life that matter or are meaningful to the individual) and engaging in actions consistent with these directions. An emphasis is placed on moment-​ to-​moment choices in everyday living and process rather than outcome. As such, valued directions require a present-​moment focus and are distinguished from goals, which are future-​oriented, static outcomes. For example, a client who values learning would be encouraged to identify a variety of discrete, concrete actions that are consistent with this valued direction and can be performed immediately, in the moment. In this case, the client would be encouraged to identify and engage in a variety of different actions consistent with the valued direction of learning, such as going to the library and reading a book of interest, researching things of interest on the internet, or joining a group for people with similar interests. Commitment to valued actions necessitates emotional willingness, in that it requires patients to remain open to experiencing the negative emotions that arise as part of engaging in these valued actions (rather than to avoid these emotions by not engaging in valued actions). The group modules are primarily didactic in nature, combining psychoeducation and in-​g roup exercises. The importance of skill generalization and daily practice is emphasized, and regular homework assignments are considered essential. Throughout the group treatment, patients complete daily monitoring forms on the emotional precipitants of their urges to engage in NSSI, as well as the consequences of their behavioral choice. Additional daily monitoring forms are tailored to the specific group module and include identifying emotions and the information provided by these emotions, distinguishing between primary and secondary emotions, identifying the consequences of emotional unwillingness versus willingness, and engaging in actions consistent with valued directions.

Empirical Support for ERGT among Women with Borderline Personality Disorder To date, four studies have provided support for the utility of ERGT in the treatment of NSSI and emotion dysregulation among women with BPD,

152  Kim L. Gratz et al.

including two open trials (Gratz & Tull, 2011; Sahlin et  al., 2017) and two randomized controlled trials (RCTs; Gratz & Gunderson, 2006; Gratz, Tull, & Levy, 2014). The first, a small RCT, found that the addition of this ERGT to participants’ ongoing outpatient therapy had positive effects on NSSI, emotion dysregulation, experiential avoidance, BPD symptoms, and symptoms of depression, anxiety, and stress (Gratz & Gunderson, 2006). Moreover, participants in the treatment condition evidenced significant changes over time on all outcome measures and reached normative levels of functioning on most. The second, an open trial examining the utility of this ERGT within a more diverse and underserved setting, found significant improvements from pre-​to post-​treatment in NSSI and other self-​destructive behaviors, emotion dysregulation, experiential avoidance, BPD, depression, anxiety, and stress symptoms, and social and vocational impairment (Gratz & Tull, 2011). The third, a larger RCT and uncontrolled nine-​month follow-​up, provided further evidence for the efficacy of this ERGT (relative to a treatment as usual only waitlist condition), revealing positive effects of this treatment on NSSI and other self-​ destructive behaviors (including substance abuse, disordered eating behaviors, risky sexual behavior, and suicidal behaviors), emotion dysregulation, BPD symptoms, depression and stress symptoms, and overall quality of life within a conservative intent-​to-​treat sample (Gratz,Tull, & Levy, 2014). Moreover, findings from the nine-​month follow-​up period provide preliminary support for the durability of treatment gains, as all improvements observed from pre-​to post-​treatment were maintained or further improved upon at follow-​up, including additional significant improvements from post-​treatment through nine-​month follow-​up for NSSI, emotion dysregulation, experiential avoidance, BPD symptoms, and quality of life (Gratz, Tull, & Levy, 2014). Finally, the most recent study, a nationwide, multi-​center, open trial of the utility of ERGT in routine clinical care in Sweden, revealed significant improvements from pre-​to post-​ treatment in NSSI and other self-​destructive behaviors, emotion dysregulation, and depression and stress symptoms (Sahlin et al., 2017). Moreover, these improvements were maintained or further improved upon at six-​month follow-​up (Sahlin et al., 2017). Notably, results also provide growing support for emotion regulation as a mechanism of change in this treatment. Specifically, across both the initial RCT and open trial samples, changes in overall emotion dysregulation over the course of this ERGT mediated the observed reductions in NSSI frequency (Gratz, Levy, & Tull, 2012). Additionally, findings from the most recent RCT revealed that improvements in overall emotion dysregulation over the course of treatment mediated the observed reductions in BPD cognitive and affective symptoms during treatment and predicted further improvements in NSSI during the nine-​month follow-​up (Gratz, Bardeen, Levy, Dixon-​Gordon, & Tull, 2015). Finally, findings from the Swedish nationwide open trial provide more rigorous support for emotion regulation as the mechanism of change in this ERGT, revealing a significant indirect effect of treatment on reductions in NSSI through improvements in emotion dysregulation (–​0.041,

Emotion Regulation Group Therapy for NSSI  153

95% CI [–​0.059, –​0.025]), with 61.5% of the total effect of time in ERGT on improvements in NSSI mediated by improvements in emotion dysregulation (Bjureberg et al., 2015). Furthermore, results of analyses examining the week-​ by-​week relations of emotion dysregulation and NSSI frequency revealed a unidirectional relation between emotion dysregulation and NSSI in support of the proposed (but not reverse) mediational model. Specifically, whereas emotion dysregulation measured at any week predicted subsequent change in NSSI frequency in the following week (p = .029), NSSI frequency measured at any week did not predict subsequent change in emotion dysregulation in the following week (p = .872; Bjureberg et al., 2015). These results provide further support for the theoretical model underlying this ERGT and add to the extant literature emphasizing the clinical utility of targeting emotion dysregulation in the treatment of NSSI and BPD (Gratz, 2007; Linehan, 1993). Finally, providing support for the transportability and potential broader applicability of this ERGT, findings from a recent study examining predictors of response to this ERGT revealed relatively few significant predictors of treatment response (despite examining a wide range of patient characteristics that could potentially influence treatment response; Gratz, Dixon-​Gordon, & Tull, 2014). Of particular importance, both demographic variables and characteristics of participants’ ongoing therapy in the community had minimal impact on treatment response (Gratz, Dixon-​Gordon, & Tull, 2014).These findings provide further support for the transportability of this treatment and its utility across a wide range of patient populations.

Recent Advances in Research on ERGT Nationwide Dissemination of ERGT in Sweden One notable advancement in research on ERGT is the dissemination of this treatment throughout the country of Sweden. Below, we describe the different phases involved in this large-​scale dissemination project, as well as specific steps taken to ensure its success. Brief History of the Dissemination Project In October 2011, the Swedish Ministry of Health and Social Affairs initiated a project aimed at developing and coordinating activities to decrease the number of young individuals engaging in NSSI throughout Sweden. The project was called The National Self-​Injury Project (NSIP), and its goal was to coordinate current knowledge on NSSI and implement empirically supported treatments for this behavior. To this end, a primary goal of this project was to improve early intervention to decrease the use of involuntary and/​or coercive treatments for NSSI. Given that this was a national initiative, three groups consisting of academic researchers, health care personnel, and project leaders were developed, with one

154  Kim L. Gratz et al.

group located in each of the three major cities in Sweden –​Stockholm, Malmo, and Gothenburg. These groups were responsible for hosting, implementing, and disseminating the different initiatives and projects launched through the NSIP. One of the first assignments of the NSIP was to conduct a review of the literature on treatments for NSSI, with the goal of identifying an empirically supported and feasible treatment that could be widely disseminated throughout the country. It was through this review that ERGT was identified as a brief, feasible treatment for NSSI with promising empirical support. Based on this review, as well as additional data presented at the First Swedish National Conference on Self-​Harm in Stockholm, Sweden (Gratz, 2012) and communication between members of the NSIP and the developers of ERGT (Drs. Gratz and Tull), the NSIP decided to co-​fund a large-​scale uncontrolled multi-​center trial of ERGT within psychiatric outpatient clinics throughout Sweden. At that time, a research team was assembled to direct the project that consisted of researchers with experience in treatment outcome research and NSSI, and the process of translating the ERGT treatment manual into Swedish commenced. ERGT Implementation Study: Pre-​Implementation Phase An invitation to participate in the implementation study of ERGT was distributed through a national network of psychiatric caregivers (with representatives from all county councils in Sweden) during the spring of 2013. Thirty-​two clinics responded to the invitation, and 15 clinics (with two therapists per clinic) were selected, although one clinic was ultimately unable to participate in the study due to local administrative difficulties, leaving a total of 14 clinics and 28 community-​based health care professionals participating in the study. All participating clinics were required to have at least one participating therapist with both (a) education within a regulated profession (e.g., a licensed nurse, psychologist, or psychotherapist), and (b) basic training in cognitive behavioral therapy (with extra training in acceptance and commitment therapy and/​or dialectical behavior therapy preferred). In selecting the participating clinics, consideration was also given to their geographical location, with the goal of obtaining as broad a national geographical representation as possible. Before the ERGT implementation study began, all therapists were required to study the ERGT manual and read relevant articles and books on NSSI and the theoretical underpinnings of ERGT. All study therapists were also required to participate in a three-​day ERGT workshop delivered by Drs. Gratz and Tull in Lund, Sweden. In addition to learning how to deliver ERGT, therapists were given detailed instructions on the study design, procedures, and measures (as therapists were responsible for identifying and recruiting participants for the study at their clinic). Prior to the delivery of ERGT, project leaders visited all clinics to ensure that project therapists understood study procedures and their own responsibilities within the project.The study was approved by the Regional Ethical Review Board in Stockholm and registered on Clinicaltrials.gov.

Emotion Regulation Group Therapy for NSSI  155

Given the large-​scale nature of this project, it was important to ensure that the participating clinics did not experience any undue burden through their participation. Thus, to facilitate participation, the NSIP reimbursed all participating clinics for the administrative costs of the implementation, allowing project leaders to have a level of control over the participating clinics (e.g., providing clinicians with protected time to prepare for the delivery of ERGT, obtain supervision, and enter study data). In addition, all materials (e.g., articles, ERGT manual, video-​cameras for taping the group sessions), research protocols, and assessments were provided free of charge to participating clinics. Further, most assessments were delivered via an internet-​based platform where patients could log in and complete assessments on their own, minimizing the administrative burden on clinicians. The research team also provided technical and practical support, and all training and supervision was provided free of cost to clinicians delivering ERGT in the participating clinics. ERGT Implementation Study: Implementation Phase The first participants began ERGT in October 2013, and between October 2013 and March 2014, 95 women with BPD or subthreshold BPD and current NSSI were recruited into the study and received ERGT. Across all participating clinics, 17 ERGT groups were conducted. During the study, regular supervision was provided to ERGT therapists to ensure that they understood the material, remained adherent with the ERGT protocol, and had the opportunity to problem-​solve any difficult situations that came up in the delivery of the group. To further ensure treatment fidelity during the ERGT study, all group sessions were filmed and reviewed weekly by clinicians fluent in Swedish and with experience in delivering ERGT. Material from these films was also used in supervision. In addition, ERGT adherence and competency forms were translated into Swedish and used as a basis for feedback on ERGT consistent and inconsistent behaviors. These forms were given to all therapists prior to delivering ERGT, and therapists were advised to use them as a guide for ensuring that the interventions delivered would be in-​line with theory underlying ERGT. Throughout the entire study period, the research group remained available to study therapists and supported them in all aspects of conducting ERGT in the context of this study (both clinical and technical). Study participants provided weekly assessments (via the internet-​based platform) of NSSI frequency, emotion dysregulation, and other self-​destructive behaviors. Therapists were instructed to ensure that participants completed their assessments each week and to provide them with time to complete the assessments before the ERGT group if needed. Therapists had access to the data of participants in their groups and were instructed to monitor the data every week. Each participant’s weekly data produced individual graphs that facilitated the monitoring of progress (or lack thereof).Therapists were instructed to check

156  Kim L. Gratz et al.

in with participants who reported increased suicidal urges or marked increases in NSSI (or NSSI behaviors that were resistant to change) during the course of ERGT. In November 2014, all therapists involved in the ERGT implementation study were invited to Stockholm to learn the results of the study. This was done out of gratitude for their commitment and hard work during the data collection phase, as well as to provide them with the opportunity to connect with the value of collecting data in the context of treatment delivery. ERGT Implementation Study: Maintenance Phase The last phase of this implementation study is to maintain the practice of ERGT at outpatient clinics throughout Sweden, enhance adherence and competence in the delivery of ERGT, and support the continued education of new therapists interested in learning and delivering ERGT. This final phase has been supported through NSIP, and since 2015, four additional ERGT workshops have been offered in Stockholm and Gothenburg, Sweden. Moreover, to ensure the continued proliferation of ERGT, ERGT supervisor trainings have been developed and conducted by Drs. Gratz and Tull. These trainings have been offered to therapists who demonstrated proficiency in delivering at least one full course of ERGT. Moreover, Drs. Gratz and Tull have begun training the supervisors of the original ERGT implementation study to deliver ERGT workshops so that ERGT training can continue to be provided throughout Sweden, especially to clinicians with less experience with the English language. As a result of this implementation study, ERGT is now a common treatment in the Swedish outpatient psychiatric system, with over 120 therapists and 15 supervisors trained in ERGT throughout Sweden. Adapting ERGT for Adolescents One of the most exciting and promising advances in research on ERGT is the recent extension of this work to adolescents. Specifically, given the strong support for the efficacy of ERGT in the treatment of NSSI among adult women with BPD, growing evidence for the clinical and public health significance of NSSI among adolescents (Jacobson & Gould, 2007), and both the paucity of and need for effective treatments for adolescents with NSSI, we adapted ERGT to provide an ERGT-​based individual therapy for adolescents (i.e., emotion regulation individual therapy for adolescents [ERITA]; Bjureberg, et al., 2017). Specifically, the primary adaptations to ERGT included:  (1) providing the treatment in an individual versus group format (to avoid any iatrogenic effects related to social contagion; e.g., Jarvi, Jackson, Swenson, & Crawford, 2013); (2) shortening the treatment to 12 weeks so that it could be provided over the course of one school semester and including a final session on relapse p­ revention (which was accomplished by combining the two sessions focused on increasing

Emotion Regulation Group Therapy for NSSI  157

emotional clarity into one session and the four sessions focused on valued directions and engagement in valued actions into two sessions); (3) simplifying the homework sheets; (4)  incorporating a youth-​friendly design and format and age-​appropriate examples; and (5)  including an internet-​delivered course with online therapist support for parents (in line with past research on family support in the treatment of adolescents with self-​harming behaviors; e.g., Brent et al., 2013). Table 9.2 provides an overview of the structure and specific topics addressed in ERITA each week. Moreover, given the important role of primary caregivers in adolescents’ daily lives, the parents of the adolescent patients were enrolled in a parent program delivered via the internet with online therapist support. This program was developed specifically to augment ERITA and consisted of four main modules and three follow-​up modules that paralleled the individual therapy sessions of ERITA.The online program combined psychoeducation with interactive exercises. The modules addressed specific parent-​related topics, such as attitudes toward NSSI and other self-​destructive behaviors, effective communication skills (e.g., validation), strategies to increase activities and interactions with the adolescent that are not focused on mental health problems, conflict management, and problem solving. An outline of the structure and topics addressed in the parent program is presented in Table 9.2. In addition to their own material, the parents also had access to the blank worksheets from the adolescents’ treatment (i.e., the psychoeducation and exercises) so that they were aware of the skills their children were learning. During the 12-​week treatment period, the parents had regular online therapist support to help problem-​solve, guide them through the program, and help with their children’s homework assignments when necessary. Notably, results of a recent open trial of ERITA for adolescents with NSSI disorder (NSSID) provide preliminary support for the feasibility, acceptability, and utility of ERITA in the treatment of NSSI and related difficulties among adolescents with NSSID (Bjureberg, et  al., 2017). Specifically, 17 adolescent girls (aged 13–​17; mean  =  15.31 ± 1.39) referred from child and adolescent mental health services in two major cities in Sweden were enrolled with their parents in the pilot study of ERITA. Intent-​to-​treat analyses revealed significant improvements associated with large effect sizes in past-​month NSSI frequency, NSSI versatility, emotion dysregulation, self-​destructive behaviors, and global functioning from pre-​to post-​treatment. Further, with the exception of NSSI versatility, all of these improvements were either maintained or further improved upon at six-​month follow-​up. Moreover, ratings of treatment credibility and expectancy and the treatment completion rate (88%) were high, and both therapeutic alliance and treatment attendance were strong. Finally, and consistent with research on ERGT (Gratz et al., 2012, 2015), change in emotion dysregulation mediated the observed improvements in NSSI during treatment. Specifically, the indirect relation of time in treatment to NSSI improvement through change in emotion dysregulation was significant (estimate = –​0.02, SE = 0.01, p = .046),

Table 9.2 Content of the ERITA and Associated Parent Program Modules Adolescent treatment

Parent program

(1)  Functions of NSSI Functions of NSSI and other self-​destructive behaviors. Introduction to the concept of valued directions. (2)  Function of emotions Facts about basic emotions, the functionality of emotions, and why it is important to be aware of emotions. (3)  Emotional awareness Increase emotional awareness by becoming aware of the different components of emotions. (4) Emotions provide information that can guide behavior How to identify the information provided by emotions and both act on that information and express emotions in healthy ways. (5)  Primary vs. secondary emotions Distinguishing between primary and secondary emotions and identifying the most effective ways of responding to each. (6)  Emotional avoidance/​unwillingness Paradoxical consequences of efforts to control/​avoid emotions and viewing self-​ destructive behaviors as an act of unwillingness (7)  Emotional willingness/​acceptance Willingness as the solution. What willingness is and is not. (8) Non-​avoidant emotion regulation strategies Adaptive strategies for modulating intense emotions. (9) Take control over impulsive behaviors Basic behavioral strategies for resisting urges to engage in impulsive behaviors. (10) Valued directions How values differ from goals. Identifying valued directions. (11)  Commitment to valued actions Identifying and committing to valued actions. (12)  Relapse prevention Identifying skills that have been helpful. Identifying high-​risk situations and strategies for preventing relapse.

(1) Psychoeducation Information about NSSI, emotional reactivity, the role of an invalidating environment, and skills in validation. (2) Repetition and homework review (3) How to improve parenting in the long run Activate yourself and your child in order to increase positive interactions. (4) Repetition and homework review (5) Conflict management and problem solving Emotional awareness and six steps for problem solving. (6) Repetition and homework review (7) Summary and evaluation Repetition and evaluation.

Emotion Regulation Group Therapy for NSSI  159

with change in emotion dysregulation accounting for 32% of the improvements in NSSI frequency (Bjureberg, et al., 2017). Internet-​Delivered  ERITA One of the main goals of adapting ERGT for use with adolescents was to develop a novel, targeted, and effective intervention that could be easily and widely implemented at a low cost. Guided internet-​based CBT (ICBT) has been shown to be highly effective for several psychiatric disorders, including depression and anxiety disorders in both adults (for a review, see Andersson, 2016) and adolescents (for a review, see Ebert et al., 2015). In ICBT, the participant follows an interactive online treatment manual and receives support and guidance from a trained professional through online communication. There is evidence to suggest that ICBT is at least as efficacious as face-​to-​face CBT for most individuals and most diagnoses (Andersson, Cuijpers, Carlbring, Riper, & Hedman, 2014; Cuijpers, Donker, van Straten, Li, & Andersson, 2010) and carries several advantages compared to traditional face-​to-​face psychological treatments that can increase accessibility to psychological treatment. Specifically, ICBT allows for less therapist time per patient, eliminates the effects of geographical distances between therapist and patient, and does not require patients to schedule appointments during their work or school day. Furthermore, given evidence that individuals with stigmatizing illnesses are more likely to use the internet than traditional health care services to seek help (Berger, Wagner, & Baker, 2005), ICBT may be particularly useful for the treatment of NSSI. Thus, following the development and pilot testing of ERITA as described above, we developed and evaluated an internet-​delivered version of ERITA that includes a greater emphasis on the practice of emotional approach, willingness, and acceptance strategies (which is covered in four of the 11 weekly modules; Bjureberg, et  al., 2018). To this end, the four sessions on emotional acceptance, awareness, and clarity in the face-​to-​face ERITA were combined into two modules, the two sessions on emotional unwillingness and willingness were combined into one module, and the sessions at the end of ERITA on valued directions and actions were covered in the first module to provide a foundation for the treatment and rationale for approaching emotions. Notably, the Child Internet Project (barninternetprojektet; BIP) in collaboration with the Karolinska Institutet and Child and Adolescent Psychiatry in Sweden has been evaluating internet-​delivered psychological treatments in Sweden since 2011. The BIP platform has currently been used in several studies of internet-​ delivered treatment for adolescents (e.g., Bonnert et  al., 2017; Lenhard et  al., 2017; Vigerland et al., 2016), and was also used for the evaluation of internet-​ delivered ERITA. The BIP platform is entirely web-​based and is designed to be used by both adolescents and their parents. ERITA is administered through this BIP platform with 11 (weekly activated) chapters including educative texts, animated films, and exercises. Internet-​delivered ERITA is currently available in

160  Kim L. Gratz et al.

Swedish, but there are plans for developing an English version. During the 12-​ week treatment period, the therapists (licensed psychologists) had regular contact via the BIP platform with the participants in order to guide them through the treatment, assist them in planning homework assignments, and problem-​ solve and answer questions when necessary. To evaluate the utility of internet-​delivered ERITA, 25 adolescents (19 girls, one boy, five other [i.e., non-​binary]) aged 13–​17 (mean age = 15.7 ± 1.3) and their parents were enrolled in an open trial (Bjureberg, et al., 2017). Preliminary results reveal findings consistent with those obtained in the face-​to-​face trial, with significant decreases in NSSI and emotion dysregulation along with high ratings of treatment credibility and expectancy, therapeutic alliance, and treatment satisfaction. Furthermore, drop-​out rates were very low (i.e., only one participant dropped out of treatment) and the majority of the participants completed all 11 chapters. These findings were consistent with qualitative analyses suggesting that the flexibility inherent in internet-​delivered treatments (i.e., when and where the participant could engage in the treatment) and support (i.e., online contact with the therapist) were important contributing factors to a positive treatment experience. Currently, a randomized controlled trial of internet-​based ERITA is being prepared and will be implemented soon. This trial will provide more rigorous data on the potential utility of ERITA for adolescents with NSSI and speak to the efficacy and broader feasibility of internet-​based ERITA.

Conclusions A growing body of research provides support for the efficacy of ERGT among women with BPD, the durability of treatment gains post-​treatment, and emotion regulation as a mechanism of change in this treatment. Recent research also suggests the utility of an adapted version of ERGT (ERITA) for adolescents with NSSI. Specifically, results of two recent pilot studies suggest that ERITA is a promising treatment for adolescents with NSSI when delivered in both traditional face-​to-​face and internet-​based formats. In addition to providing further support for the potential broader applicability of ERGT and ERGT-​ based treatments, the promising results of the internet-​based ERITA pilot study, combined with the findings of the Swedish nationwide open trial of ERGT, provide converging evidence of the feasibility and transportability of ERGT.

References Andover, M. S., Schatten, H. T., Morris, B. W., Holman, C. S., & Miller, I. W. (2017). An intervention for nonsuicidal self-​injury in young adults: A pilot randomized controlled trial. Journal of Consulting and Clinical Psychology, 85(6), 620–​631. Andersson, G. (2016). Internet-​ delivered psychological treatments. Annual Review of Clinical Psychology, 12, 157–​179.

Emotion Regulation Group Therapy for NSSI  161 Andersson, G., Cuijpers, P., Carlbring, P., Riper, H., & Hedman, E. (2014). Guided Internet-​based vs. face-​to-​face cognitive behavior therapy for psychiatric and somatic disorders: A systematic review and meta-​analysis. World Psychiatry, 13, 288–​295. Asarnow, J.  R., Porta, G., Spirito, A., Emslie, G., Clarke, G., Wagner, K.  D., … Brent, D. A. (2011). Suicide attempts and nonsuicidal self-​injury in the treatment of resistant depression in adolescents: Findings from the TORDIA study. Journal of the American Academy of Child & Adolescent Psychiatry, 50, 772–​781. Berger, M., Wagner, T.  H., & Baker, L.  C. (2005). Internet use and stigmatized illness. Social Science & Medicine, 61, 1821–​1827. Bjureberg, J., Sahlin, H., Hedman, E., Jokinen, J., Tull, M. T., Gratz, K. L., … Ljótsson, B. (2015). Emotion regulation as a mechanism of change in the treatment of nonsuicidal self-​injury in BPD. Presentation given at the annual meeting of the North American Society for the Study of Personality Disorders, Boston, MA. Bjureberg, J., Sahlin, H., Hedman-​Lagerlöf, E., Jokinen, J., Gratz, K. L., Tull, M. T., … Ljótsson, B. (2018). Extending research on emotion regulation individual therapy for adolescents (ERITA) with nonsuicidal self-​injury:  Open pilot trial and mediation analysis of a novel online version. BMC Psychiatry, 18, 326. doi:10.1186/​ s12888-​018-​1885-​6 Bjureberg, J., Sahlin, H., Hellner, C., Hedman, E., Gratz, K. L., Bjärehed, J., … Ljótsson, B. (2017). Emotion regulation individual therapy for adolescents with nonsuicidal self-​ injury disorder:  A feasibility study. BMC Psychiatry, 17(1), 411. doi:10.1186/​ s12888-​017-​1527-​4. Bonnert, M., Olén, O., Lalouni, M., Benninga, M.  A., Bottai, M., Engelbrektsson, J., … Ljótsson, B. (2017). Internet-​delivered cognitive behavior therapy for adolescents with irritable bowel syndrome:  A randomized controlled trial. American Journal of Gastroenterology, 112, 152–​162. Brent, D. A., McMakin, D. L., Kennard, B. D., Goldstein, T. R., Mayes, T. L., & Douaihy, A. B. (2013). Protecting adolescents from self-​harm: A critical review of intervention studies. Journal of the American Academy of Child and Adolescent Psychiatry, 52, 1260–​1271. Chapman, A.  L., Gratz, K.  L., & Brown, M.  Z. (2006). Solving the puzzle of deliberate self-​harm: The experiential avoidance model. Behavior Research and Therapy, 44, 371–​394. Cole, P. M., Michel, M. K., & Teti, L. O. (1994). The development of emotion regulation and dysregulation: A clinical perspective. Monographs of the Society for Research in Child Development, 59, 73–​100. Cuijpers, P., Donker, T., van Straten, A., Li, J., & Andersson, G. (2010). Is guided self-​ help as effective as face-​to-​face psychotherapy for depression and anxiety disorders? A systematic review and meta-​analysis of comparative outcome studies. Psychological Medicine, 40, 1943–​1957. Ebert, D. D., Zarski, A.-​C., Christensen, H., Stikkelbroek,Y., Cuijpers, P., Berking, M., & Riper, H. (2015). Internet and computer-​based cognitive behavioral therapy for anxiety and depression in youth: A meta-​analysis of randomized controlled outcome trials. PLoS ONE, 10(3), e0119895–​15 Ekman, P.  E. & Davidson, R.  J. (1994). The nature of emotion:  Fundamental questions. New York: Oxford University Press. Glenn, C.  R., Franklin, J.  C., & Nock, M.  K. (2015). Evidence-​based psychosocial treatments for self-​injurious thoughts and behaviors in youth. Journal of Clinical Child & Adolescent Psychology, 44, 1–​29.

162  Kim L. Gratz et al. Gratz, K. L. (2003). Risk factors for and functions of deliberate self-​harm: An empirical and conceptual review. Clinical Psychology: Science and Practice, 10, 192–​205. Gratz, K.  L. (2007). Targeting emotion dysregulation in the treatment of self-​injury. Journal of Clinical Psychology, 63, 1091–​1103. Gratz, K. L. (2012). Efficacy of an acceptance-​based emotion regulation group therapy for self-​harm among women with borderline personality pathology:  Randomized controlled trial and nine-​month follow-​up. Invited Keynote Address given at the First Swedish National Conference on Self-​Harm, Stockholm, Sweden. Gratz, K.  L., Bardeen, J.  R., Levy, R., Dixon-​Gordon, K.  L., & Tull, M.  T. (2015). Mechanisms of change in an emotion regulation group therapy for deliberate self-​ harm among women with borderline personality disorder. Behavior Research and Therapy, 65, 29–​35. Gratz, K. L., Dixon-​Gordon, K. L., & Tull, M. T. (2014). Predictors of treatment response to an adjunctive emotion regulation group therapy for deliberate self-​harm among women with borderline personality disorder. Personality Disorders: Theory, Research, and Treatment, 5, 97–​107. Gratz, K. L. & Gunderson, J. G. (2006). Preliminary data on an acceptance-​based emotion regulation group intervention for deliberate self-​harm among women with borderline personality disorder. Behavior Therapy, 37, 25–​35. Gratz, K.  L., Levy, R., & Tull, M.  T. (2012). Emotion regulation as a mechanism of change in an acceptance-​ based emotion regulation group therapy for deliberate self-​harm among women with borderline personality pathology. Journal of Cognitive Psychotherapy, 26, 365–​380. Gratz, K.  L., & Roemer, L. (2004). Multidimensional assessment of emotion regulation and dysregulation:  Development, factor structure, and initial validation of the Difficulties in Emotion Regulation Scale. Journal of Psychopathology and Behavioral Assessment, 26, 41–​54. Gratz, K.  L. & Tull, M.  T. (2010). Emotion regulation as a mechanism of change in acceptance-​and mindfulness-​based treatments. In R. A. Baer (Ed.), Assessing mindfulness and acceptance: Illuminating the processes of change (pp. 107–​134). Oakland, CA: New Harbinger Publications. Gratz, K.  L. & Tull, M.  T. (2011). Extending research on the utility of an adjunctive emotion regulation group therapy for deliberate self-​harm among women with borderline personality pathology. Personality Disorders:  Theory, Research, and Treatment, 2, 316–​326. Gratz, K. L., Tull, M. T., & Levy, R. (2014). Randomized controlled trial and uncontrolled 9-​month follow-​up of an adjunctive emotion regulation group therapy for deliberate self-​harm among women with borderline personality disorder. Psychological Medicine, 44, 2099–​2112. Guan, K., Fox, K. R., & Prinstein, M. J. (2012). Nonsuicidal self-​injury as a time-​invariant predictor of adolescent suicide ideation and attempts in a diverse community sample. Journal of Consulting and Clinical Psychology, 80, 842. Gunderson, J.  G. (2001). Borderline personality disorder:  A clinical guide. Washington, DC: American Psychiatric Publishing. Jacobson, C. M., & Gould, M. (2007). The epidemiology and phenomenology of non-​ suicidal self-​injurious behavior among adolescents: A critical review of the literature. Archives of Suicide Research, 11, 129–​147.

Emotion Regulation Group Therapy for NSSI  163 Jarvi, S., Jackson, B., Swenson, L., & Crawford, H. (2013). The impact of social contagion on non-​suicidal self-​injury: A review of the literature. Archives of Suicide Research, 17,  1–​19. Hayes, S. C., Luoma, J. B., Bond, F. W., Masuda, A., & Lillis, J. (2006). Acceptance and commitment therapy: Model, processes and outcomes. Behavior Research and Therapy, 44,  1–​25. Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (1999). Acceptance and commitment therapy: An experiential approach to behavior change. New York: Guilford Press. Lenhard, F., Andersson, E., Mataix-​Cols, D., Rück, C., Vigerland, S., Högström, J., … Serlachius, E. (2017). Therapist-​ guided, Internet-​ delivered cognitive-​ behavioral therapy for adolescents with obsessive-​compulsive disorder: A randomized controlled trial. Journal of the American Academy of Child & Adolescent Psychiatry, 56, 10–​19. Linehan, M.  M. (1993). Cognitive-​ behavioral treatment of borderline personality disorder. New York: Guilford Press. Mack, J. (1975). Borderline states in psychiatry. New York: Grune & Stratton. Sahlin, H., Bjureberg, J., Gratz, K. L., Tull, M. T., Hedman, E., Bjärehed, J., … Gumpert, C.  H. (2017). Emotion regulation group therapy for deliberate self-​harm:  A multi-​ site evaluation in routine care using an uncontrolled open trial design. BMJ Open, 7, e016220. Salters-​Pedneault, K., Tull, M. T, & Roemer, L. (2004). The role of avoidance of emotional material in the anxiety disorders. Applied and Preventive Psychology, 11, 95–​114. Taylor, L. M., Oldershaw, A., Richards, C., Davidson, K., Schmidt, U., & Simic, M. (2011). Development and pilot evaluation of a manualized cognitive-​behavioral treatment package for adolescent self-​harm. Behavioral and Cognitive Psychotherapy, 39, 619. Thompson, R. A. (1994). Emotion regulation: A theme in search of definition. Monographs of the Society for Research in Child Development, 59, 25–​52. Tyrer, P., Tom, B., Byford, S., Schmidt, U., Jones, V., Davidson, K., … POPMACT Group. (2004). Differential effects of manual assisted cognitive behavior therapy in the treatment of recurrent deliberate self-​ harm and personality disturbance:  The POPMACT Study. Journal of Personality Disorders, 18, 102–​116. Vigerland, S., Ljótsson, B., Thulin, U., Öst, L.-​G., Andersson, G., & Serlachius, E. (2016). Internet-​delivered cognitive behavioral therapy for children with anxiety disorders: A randomised controlled trial. Behavior Research and Therapy, 76, 47–​56. Wilkinson, P., Kelvin, R., Roberts, C., Dubicka, B., & Goodyer, I. (2011). Clinical and psychosocial predictors of suicide attempts and nonsuicidal self-​injury in the Adolescent Depression Antidepressants and Psychotherapy Trial (ADAPT). The American Journal of Psychiatry, 168, 495–​501. Zanarini, M. C. (2009). Psychotherapy of borderline personality disorder. Acta Psychiatrica Scandinavica, 120, 373–​377.

Chapter 10

Atypical, Severe Self-​I njury How to Understand and Treat It Barent W. Walsh

Introduction The overwhelming majority of publications on NSSI have focused on common forms of the behavior including cutting, scratching, abrading, burning, or self-​ hitting. These behaviors have generally been inflicted on the extremities or abdomen. In addition, the majority of these behaviors, studied both in community (e.g., Whitlock et al., 2011) and clinical samples (e.g., Washburn, Juzwin, Styer, & Aldridge, 2010), have not required medical attention. There have been only a few contributions to the literature regarding atypical and severe NSSI. For example, Buser and colleagues (2017) reported in a study of 102 college students that “unintentionally severe NSSI” was associated with “addictive qualities” of the behavior. In contrast to the population described by Buser et al., the forms of NSSI discussed in this chapter are intentionally more severe, not accidental. In another recent report, Ammerman and colleagues (2018) found in a sample of 957 undergraduates that severity of self-​harm in NSSI was associated with age of onset (before age 12). This finding bears further consideration. The focus of this chapter will be to review more extreme NSSI behaviors primarily found in clinical settings. The chapter will attempt to explicate these behaviors and will provide suggestions for treatment. In addition, I will propose that atypical, severe NSSI be considered a different category of behavior, distinct from common, low-​lethality NSSI. I will also propose that atypical NSSI, despite being more severe, can also be differentiated from suicide attempts.

Three Subtypes of Atypical, Severe NSSI In this chapter, three major subtypes of atypical, severe NSSI are defined. These are: • •• •

NSSI requiring medical attention such as sutures, glue, bandages, antiseptic salves NSSI to unusual body areas: face, eyes, breasts, and genitals Foreign body ingestion

Atypical, Severe Self-Injury  165

Why might these three types of behavior properly be considered “atypical and severe”? First of all, as noted above, the large majority of wounds associated with NSSI do not require medical attention. When someone injures him-​or herself and requires medical attention, the behavior is not only unusual, it is also suggestive of a greater level of distress. For example, reflect on a time –​perhaps in childhood –​when you were accidentally injured and the wound required medical treatment, such as stitches. Now imagine individuals intentionally inflicting a wound that requires 10 or 100 sutures to repair. Alternatively, imagine individuals deliberately ingesting an object that requires an endoscopy. It is not extreme to speculate that such persons must be experiencing profound distress. The amount of damage can be viewed –​like an equation –​as directly related to the intensity and degree of distress and an inability to manage said distress. Second, the location on the body of NSSI matters. Most people who self-​ injure damage wrists, forearms, shoulders, legs, or abdomen (for reviews, see Klonsky, 2007; Nock, 2010). In contrast, few individuals wound the face. As humans, we present to each other first and foremost via our faces. We recognize each other using our faces, not our hands, feet, or shoulders. We also use facial characteristics to detect emotions and communicate non-​verbally. When persons intentionally injure the face, it suggests an alarming level of social disconnection. People seem to be thinking, “I don’t care how I look or how I impact others,” and “I’m willing to ‘de-​face’ myself.” Wounding the eyes is even more alarming. Eyes are sensitive organs. They provide the fundamentally important function of sight. Wounds to the eye have no guarantee of fully healing; people risk permanent impairment. Persons who intentionally wound their eyes are generally in very grave crises indeed. On the extreme end of the continuum are those who self-​enucleate. Often, individuals who remove their own eyes are psychotic (Walsh & Rosen, 1988). Fortunately, NSSI involving the eyes is very rare. Grossman (2001) identified only 90 cases of ocular self-​injury in the modern psychological literature since the late nineteenth century. Similar alarm is appropriate for those who damage the breasts (in females) or genitals (in either gender). Fortunately, this behavior also appears to be quite rare. For example, Grossman noted that only “115 cases of male genital self-​ mutilation have been reported in English, German, and Japanese literature since the end of the nineteenth century” (Grossman, 2001, p.  53). There are numerous reasons why harming the breasts or genitals is especially concerning. First, these body areas are replete with nerve endings. Persons deliberately damaging these areas appear to have very unusual relationships with physical pain, even beyond a typical individual with NSSI. Often such persons deny pain at the time of their acts. This may be due to desensitization of the pain response due to marked repetition of NSSI, or possibly a higher innate pain threshold. In addition, when clinicians encounter individuals who injure their breasts or genitals, they should carefully assess for either PTSD and/​or psychotic decompensation. These body areas have obvious real-​world importance and symbolic

166  Barent W. Walsh

significance as to sexuality. In my clinical experience, it is not unusual that such persons report “punishing” their sexual organs for past “involvement” in sexually abusive, traumatic experiences or due to command hallucinations about “sinful” aspects of sexuality. Foreign body ingestion (FBI) is an especially puzzling form of NSSI. It involves people deliberately ingesting inedible objects such as screws, nails, shards of plastic, coins, pebbles, razor blades, tooth brushes, tools, eating utensils, etc. (see Walsh, 2012, and Poynter, Hunter, Coverdale, & Kampinsky, 2011 for review articles). FBI can be hard to categorize; is FBI an example of suicidal behavior, NSSI, or some other form of self-​harm? We believe it to be a form of atypical, severe NSSI because: • •• •• •

It is intentionally self-​destructive, yet most individuals deny suicidal intent Consistent with these reports, very few individuals die from FBI While not suicidal, it is alarming as to potential for physical damage –​much more so than with common, low-​lethality NSSI Similar to other forms of NSSI, it does result in direct bodily harm, most frequently gastritis, esophagitis, gastro-​esophageal reflux disease (GERD), and much more rarely, blockage, perforation, peritonitis, etc. (American Society for Gastrointestinal Endoscopy, 2002). In some cases, the amount of damage can be microscopic

Despite these similarities with NSSI, FBI is different from other forms of NSSI in that the bodily harm is not immediately visible to the perpetrator or others. This is very different from all other forms of self-​injury for which wounds on extremities or other body areas are instantly evident. In fact, with FBI, the behavior can be invisible to self and others for hours, days, and even weeks. Nonetheless, FBI does adhere to the definition of self-​injury provided in Walsh (2017): it is “intentional, non-​life-​threatening, self-​effected bodily harm … of a socially unacceptable nature, performed to reduce psychological distress and/​or effect change in others.”

A Study with Findings Regarding Atypical NSSI Walsh and Doerfler (2016) examined a clinical sample with a broad range of self-​destructive and risk behaviors, including atypical severe NSSI.The sample consisted of 467 male and female adults living in intensive community-​based group homes or supported housing programs. These were operated by The Bridge, a human service agency in Massachusetts. Data were collected on 28 categories of risk (occurring over the previous six months or lifetime) pertaining to: •

Self-​ destructive behaviors  –​including suicide thoughts, plans, actions; atypical severe NSSI; common, low-​ lethality NSSI; eating disorders;

Atypical, Severe Self-Injury  167

•• •• •

substance abuse; risk-​taking behaviors; recurrent psychotropic medication non-​compliance Physical health and longevity –​including coping with/​managing serious medical illness; physical mobility challenges; inability to avoid danger Trauma  –​including physical and/​or sexual abuse during childhood and recent physical and/​or sexual abuse Public safety  –​including violence towards others; problematic sexual behavior; fire-​setting; unwarranted 911 calls; other illegal behavior

The following five of the 28 risk categories emerged as having significantly high percentage of risk behaviors (well above the mean of 2.4 per subject): • •• •• •• •

Atypical self-​injury –​  380% Recent physical and/​or sexual abuse –​ 345% Suicidal actions –​ 340% Physical restraint in the program –​ 320% Unwarranted 911 calls –​ 320%

As shown above, each of these five risk indicators have total scores that are more than three times the overall mean for the entire sample. Further, atypical, severe NSSI ranked first with those subjects having 380% more risk behaviors than the average. This finding suggests that individuals with atypical, severe NSSI may be likely to present with a cluster of high-​r isk behaviors. Accordingly, atypical self-​injury may be an important marker for serious psychopathology and related clinical risk. These conclusions were supported by an additional study by Hom and colleagues (unpublished data analyses), who further examined this data set from The Bridge. They reported the following: … both a lifetime and recent history of atypical NSSI was associated with significantly increased risk for suicidal thoughts and behaviors. Findings suggest that individuals with a history of atypical NSSI may comprise a group with severe psychopathology and acute suicide risk.Thus, it may be clinically useful to probe the types of NSSI in which a client is engaging and to consider individuals with a history of atypical NSSI as a high-​risk subgroup (Hom et al., unpublished data analyses, 2017).

Functions of Atypical, Severe NSSI A well-​accepted strategy for analyzing the functions of NSSI was provided via Nock and Prinstein’s (2004) four-​component model. As shown in Table 10.1, the model includes positive and negative intrapersonal functions and positive and negative interpersonal functions. As there are no studies of atypical severe NSSI that address functions in detail, the content in Tables 10.1, 10.2 and 10.3 come from my own clinical experience. As a result, these need to be viewed as clinically

168  Barent W. Walsh Table 10.1 Functions for Atypical NSSI Requiring Medical Attention Positive Intrapersonal Reinforcers “I deserve extensive damage. Superficial cuts don’t do the job. That’s for wimps.” “It’s a positive relief to inflict pain and damage on myself.” “The pain feels good.” “I feel exhilarated or high when I do more serious damage.”

Negative Intrapersonal Reinforcers “I have to cut deep to get relief from my intense emotional distress.” “Superficial damage doesn’t work.”

Table 10.2 Functions for Atypical NSSI of Unusual Body Areas Positive Intrapersonal Reinforcers Face: “I deserve to be disfigured.” “I’m already ugly; why not make it more so?” Sex organs: “I know this sounds weird, but hurting my genitals can be a turn on.” Positive Interpersonal Reinforcers

Negative Intrapersonal Reinforcers Eyes: “My voices are so loud and demanding, I have to obey them.” Sexual organs: “I know it’s crazy but when I hurt my genitals I feel relief from guilt and shame about my abuse.” “I have to punish my genitals to get relief.” Negative Interpersonal Reinforcers Face: “People will avoid me. I prefer social isolation.” Sexual organs: “People will not approach me sexually because I am disfigured, unattractive.”

informed speculations. Please note that the functions provided in Table 10.1 pertain to self-​injury involving damage that requires medical attention. Table 10.2 addresses unusual body areas, and Table 10.3, foreign body ingestion. Note that in Table 10.1, the reinforcers provided are all in the intrapersonal realm.The statements in quotations are from clients served at The Bridge. In our experience, it is very rare that NSSI requiring medical intervention is reinforced socially or in an environment. Persons do these behaviors because of profound, unmanageable emotional distress; others recoil at the damage. Table 10.2 presents speculations about atypical NSSI involving unusual body areas. For these behaviors the functions fall both into the intrapersonal and interpersonal realms. Items in quotation are direct quotes from clients who have presented with NSSI inflicted on unusual body areas. Table  10.3 refers to foreign body ingestion (FBI). The functions provided in this table come from a qualitative study by Walsh and Perry (2012; in Walsh, 2012). The study involved interviewing nine individuals who had presented with recurrent FBI and were residing in state hospitals or correctional facilities. Subjects were asked, “What does ingesting do for you?” The responses in Table 10.3 are taken verbatim from the nine individuals.

Atypical, Severe Self-Injury  169 Table 10.3 Functions of FBI for Nine Individuals Positive Self-​Reinforcement “To have a sensation of food in my stomach.” Positive Social-​Reinforcement “I like the doctor at the ER; he’s cute.” “I like the scopes at the medical unit.” “I like the people and get high off the sedatives they give me.” “I want control of my treatment.” “It’s like playing Russian roulette and slapping god in the face.”

Negative Self-​Reinforcement “Sense of relief.” “I thought the battery would explode and kill me.” “Same function as cutting.” Negative Social-​Reinforcement “I don’t want to be here: I want to go to the medical hospital.” “When I swallow objects, I get transferred off the ward to a medical unit.” “I get transferred from the cellblock to the medical unit.” “I want a sharp object lodged in my anus so that when someone rapes me, he will get his dick shredded.”

What is especially striking about the functions of FBI for these persons was that the social reinforcers were generally much more important than the internal reinforcers. This finding is very different from most other studies of self-​injury (Klonsky, 2007; Nock, 2010), where the primary motivations for FBI have been internal affect regulation. Only two of the nine patients cited internal affect regulation as a reason for their FBI and these were of secondary importance. The most common explanation voiced by these patients was that they ingested in order to be transferred from their psychiatric wards or cellblock to medical facilities. In some cases, they sought this transfer because they found the medical staff to be more nurturing and compassionate. Many of the patients expressed a desire to escape their psychiatric wards or cellblocks due to ongoing interpersonal conflicts with staff and other patients/​inmates. Other patients indicated they “liked the scopes” or sedatives associated with endoscopies. For those working with individuals who present with atypical severe NSSI, the four-​function model can be very useful in understanding the behavior and designing treatment strategies, which is the next topic to be discussed.

Treating Individuals with Atypical Severe NSSI If individuals with these atypical NSSI behaviors are prone to: (1) clusters of other risk behaviors, and (2) elevated risk for suicide thoughts and behaviors, how do we treat them? While there are certainly no rigorous studies regarding such treatment, we can at least propose reasonable clinical guidelines.

Hierarchy of Risk First, in treating people with atypical, severe NSSI it is logical to employ a “hierarchy of risk” (Walsh, 2012) because these are individuals with multiple self-​harm

170  Barent W. Walsh

behaviors in combination. It is neither practical –​nor reasonable –​to expect such individuals to overcome all these self-​destructive acts at the same time.Yet, we often see treatment plans in programs or inpatient facilities that read, “client [or patient] will refrain from self-​harm behaviors for the next 30 days.” Such treatment goals are generally a prescription for failure. A more realistic strategy is to employ a hierarchy that targets the most potentially lethal behaviors first and then moves to the next most alarming, etc. For example, a poly-​self-​destructive individual (Walsh, 2012) might merit a treatment plan with hierarchical goals of reducing/​eliminating: 1 . 2. 3. 4. 5.

Suicide plans and rehearsal regarding overdose Abuse of a prescribed opiate Atypical severe self-​injury via cutting involving sutures or FBI Moderate binge-​eating Common low-​lethality self-​injury of extremities not requiring medical attention

An individual with a simpler (but not unchallenging) combination of problems might employ a hierarchy like this: 1 . Atypical severe NSSI –​reopening sutured wounds 2. Episodic bingeing on alcohol 3. Cutting of extremities not requiring medical attention

Sequential, Multi-​M odal Treatments A second clinical principle is to employ a series of evidence-​based treatment sequentially.We have done this with many clients at The Bridge. A common place to start is providing dialectical behavior therapy (DBT; Linehan, 2015) according to protocol. Learning the DBT skills of mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness provides the bedrock toolkit for other subsequent treatments.The intense emotional distress that generally triggers atypical severe NSSI must become manageable if clients are to give up the behaviors. In addition, clients need to master the interpersonal effectiveness skills that allow individuals to ask for help before self-​injuring. And they need to learn conflict resolution skills which can reduce triggers for subsequent NSSI. Once clients have participated in one to two rounds of DBT (generally lasting six months each), they can move into more specialized treatments.There may be a dosage effect. An outcome study of DBT with adolescents conducted at The Bridge showed significant reductions in suicidal behavior, NSSI, and psychiatric hospitalizations for the study subjects who had completed one to two rounds compared to individuals who had completed less than one round (Walsh, Doerfler & Perry, in Walsh, 2012). A common second treatment that we offer is cognitive restructuring (CR) for PTSD (Mueser, Rosenberg, & Rosenberg, 2009; Walsh, 2012). The large

Atypical, Severe Self-Injury  171

majority of clients who have presented with atypical self-​injury have histories of trauma. For example, in a qualitative study of nine individuals who presented with FBI referenced above (Walsh, 2012), all nine (or 100%) had been sexually abused as children. In addition, six of nine (67%) had been physically abused. These individuals had clearly experienced extremely problematic childhoods. We selected CR for PTSD as the evidence-​based treatment because it is a non-​exposure treatment. We have found that many Bridge clients are unable to tolerate treatments that involve prolonged exposure (e.g., Foa, Hembree, & Rothbaum, 2007). Instead, their self-​destructive behaviors are often exacerbated during treatment. In contrast, CR for PTSD is a 12–​16-​week, manualized treatment that teaches breathing retraining and provides psychoeducation about PTSD symptoms. The heart of the treatment is cognitive restructuring and action planning. Rather than requiring detailed discussion of past traumatic events (exposure), the treatment targets the thoughts and beliefs derived from the trauma. For example, the treatment focuses on inaccurate, unhelpful beliefs that are common in individuals with PTSD such as, “the abuse must have been my fault because it went on so long,” or “I broke up the family when I told someone,” or “my body is contaminated by the abuse.” In addition to Mueser’s empirical support for the efficacy of CR for PTSD (Mueser et al. 2015), we have data for the first 88 clients served with CR at The Bridge which indicate significant reductions in both PTSD and depression scores (Walsh, 2017). A third evidence-​based treatment we have provided to individuals who present with atypical, severe NSSI and other related self-​harm behaviors has been the illness, management and recovery (IMR) model (McGuire et  al. 2016; Mueser et al., 2006). This treatment is designed for persons with serious mental illness (especially psychosis) who are prone to decompensation and relapse. This treatment is a better match for persons with psychosis than DBT –​which emphasizes dealing with emotion dysregulation. IMR is quite useful in reducing self-​harm behaviors in this population because of its very structured, manualized approach –​which is a good match for cognitively disorganized individuals. The manual for IMR has 10 modules that cover the topics of: Recovery Strategies; Practical Facts about Mental Illness; Stress–​Vulnerability Model; Building Social Support; Using Medication Effectively; Reducing Relapse; Coping with Stress; Coping with Symptoms; Getting Your Needs Met in the Mental Health System; Drug and Alcohol Use. Moreover, IMR is based on a recovery model that emphasizes personal choice and self-​determination (Mueser et al., 2006). Other specialized evidence-​based treatments that we have offered individuals with atypical NSSI have included CBT for eating disorders (Fairburn, 2008), CBT for aggression (Reilly & Shopshire, 2002), and CBT for psychosis (Turkington & Kingdon, 2005). This chapter concludes with two case examples that demonstrate the sequential use of evidence-​based treatments in the treatment of atypical NSSI and other problem behaviors. One has had a negative outcome (to date) and the other a very positive conclusion.

172  Barent W. Walsh

Case Example 1 Ms. M is a 38-​year-​old woman with a long history of institutionalization. She has presented with 19 of the 28 risk behaviors described above, including suicide attempts, atypical severe NSSI (i.e., cutting with many sutures, FBI), common NSSI, substance abuse, eating disorder, failure to take prescribed medication, etc. She has been attempting to live in the community in her own apartment; however, she has been chronically unstable with many ER visits per month and several psychiatric hospitalizations per quarter. Her insurance payor assumed $30,000 in ambulance charges within the past six months. She has potential damage to her esophagus due to frequent FBI, related scopes and x-​rays. She also is recurrently suicidal with specific plans. Her major treatment challenge is that she has refused to engage in evidence-​based treatments. When she has attempted to engage in treatment, her community tenures have been so short due to hospitalizations that she has missed an excessive number of sessions. Her ability to reside in the community is tenuous at best. She is likely to return to a state hospital for an extended stay.

Case Example 2 This 26-​ year-​ old woman entered a community-​ based residential treatment program 3.5  years ago, having been discharged from a state hospital. The program offered on-​site IMR with which she immediately engaged. She identified her recovery goals as: (1) reducing self-​harm behaviors, and (2) moving to her own apartment. Prior to entering in the program, she had presented with 16 of the 28 risk behaviors including suicide attempts, atypical NSSI (cutting with sutures, FBI), extensive superficial cutting, obesity, alcohol abuse, medication, non-​compliance with medications, elopements, sexual risk-​taking, etc. Over the first six months of treatment she made progress on her “hierarchy of risk.” She became adept at communicating suicide urges with staff in the program and was able to cease suicide attempts. She also had no instances of atypical severe NSSI, although she continued to occasionally cut her skin.These behaviors were managed within the program without resorting to psychiatric hospitalizations. Within six months in the program she also began attending DBT groups offered by the agency. This treatment prepared her to do trauma work related to her history of sexual and violent abuse as a child. After a year of DBT, she completed CR for PTSD with notable reductions in her PTSD and depression scores. A year later she graduated to her own apartment and is now receiving intensive supported housing services. She has several enduring friendships in the community and works part-​time in a bakery. She remains stable and safe!

Conclusion Atypical, severe NSSI can be conceptualized as comprised by three subgroups: (1) injury requiring medical attention; (2) injury to unusual body parts including

Atypical, Severe Self-Injury  173

face, eyes, breasts, and genitals; and (3)  foreign body ingestion. These three subgroups may have different functions, ranging from intrapersonal to interpersonal. These different subtypes of atypical severe NSSI share a key marker for severe psychopathology, other risk behaviors, and suicide attempts. Atypical, severe NSSI, however, is vastly under-​researched; it merits significantly more attention because of the clinical risks posed by the behavior. Even with the limited research available, clinicians still must treat atypical, severe NSSI. A reasonable approach to treatment of atypical, severe NSSI and related problems may be with a hierarchy of risk and sequential evidence-​based treatments.

References American Society for Gastrointestinal Endoscopy. (2002). Guideline for the management of ingested foreign bodies. Gastrointestinal Endoscopy, 55, 802–​806. Ammerman, B.  A., Jacobucci, R., Kleiman, E.  M., Uyeji, L.  L., & McCloskey, M.  S. (2018). The relationship between nonsuicidal self-​injury age of onset and severity of self-​harm. Suicide and Life-​Threatening Behavior, 48, 31–​37. doi:10.1111/​sltb.12330 Buser, T. J., Buser, J. K., & Rutt, C. C. (2017). Predictors of unintentionally severe self-​ harm during nonsuicidal self-​injury. Journal of Counseling and Development, 95, 14–​23. DOI:10.1002/​jcad.12113 Fairburn, C. G. (2008). Cognitive behavior therapy and eating disorders. New York: Guilford. Foa, E., Hembree, E., & Rothbaum, B.  O. (2007). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences therapist guide. Oxford: Oxford University Press. Grossman, R. (2001). Psychotic self-​injurious behaviors: Phenomenology, neurobiology, and treatment. In D. Simeon & E. Hollander (Eds.), Self-​injurious behaviors: Assessment and treatment. Washington, DC: American Psychiatric Association. Hom, M. A., Rogers, M. L., Schneider, M. E., Chiurliza, B., Doerfler, L., Walsh, B.W., & Joiner, T. E. (2017). Atypical non-​suicidal self-​injury as an indicator of severe psychopathology and suicide risk: Findings from a sample of high-​risk community mental health clients. Unpublished. Klonsky, E. D. (2007). The functions of deliberate self-​injury: A review of the evidence. Clinical Psychology Review, 27, 226–​239. Linehan, M. M. (2015). DBT skills training manual, 2nd edition. New York: Guilford Press. McGuire, A. B., Kukla, M., Green, A., Gilbride, D., Mueser, K. T., & Salyers, M. P. 2016). Illness management and recovery: A review of the literature (2014). Psychiatric Services, 65(2), 171–​170. doi:10.1176/​appi.ps.201200274. Mueser, K. T., Gottlieb, J. D., Xie, H.,Yanos, P. T., Rosenberg, S. D., Silverstein, S. M. … McHugo, G. J. (2015). Evaluation of cognitive restructuring for post-​traumatic stress disorder in people with severe mental illness. British Journal of Psychiatry, 205(6), 501–​ 508. doi:10.1192/​bip.bp.114.147926. Mueser, K. T., Meyer, P. S., Penn, D. L., Clancy, R., Clancy, D. M., & Salyers, M. P. (2006). The illness management and recovery program: Rationale, development, and preliminary findings. Schizophrenia Bulletin, 32, 32–​43. Mueser, K. T., Rosenberg, S. D., & Rosenberg, H. J. (2009). Treatment of posttraumatic stress disorder in special populations: A cognitive restructuring program. Washington, DC: American Psychological Association. Nock, M. K. (2010). Self-​injury. Annual Review of Clinical Psychology, 6, 339–​363.

174  Barent W. Walsh Nock, M. K. & Prinstein, M. J. (2004). A functional approach to the assessment of self-​ mutilative behavior. Journal of Consulting and Clinical Psychology, 72(5), 885–​890. Poynter, B.  A., Hunter, J.  J., Coverdale, M.  D., & Kampinsky, C.  A. (2011). Hard to swallow: A systematic review of deliberated foreign body ingestion. General Hospital Psychiatry, 33, 5, 518–​524. Reilly, P. M. & Shopshire, M. S. (2002) Anger management for substance abuse and mental health clients, a CBT manual. Rockville, MD: SAMHSA. Turkington, D.  G. & Kingdon, D. (2005). Cognitive therapy of schizophrenia. New  York: Guilford. Walsh, B.  W. (2012). Treating self-​ injury:  A practical guide, 2nd edition. New  York: Guilford Press. Walsh, B. W. (April 2017). Workshop on “Understanding, Managing and Treating Non-​ Suicidal Self-​Injury,” at the American Association of Suicidology Annual Meeting, Phoenix, AZ. Walsh, B.  W. & Doerfler, L.  A. (December 2016). Van Gogh’s ear:  Why atypical, severe self-​injury is an especially alarming form of self-​harm. Presentation at the Harvard Medical School/​Cambridge Health Alliance conference on Treating Self-​Destructive Behavior, Boston, MA. Walsh, B. W., Doerfler, L. A., & Perry, A. (2012). Residential treatment for adolescents targeting self-​injury and suicidal behavior. In B. W. Walsh (Ed.). Treating self-​injury: A practical guide, 2nd edition. New York: Guilford Press. Walsh, B.  W., & Rosen, P.  M. (1988). Self-​ mutilation:  Theory, research and treatment. New York: Guilford Press. Washburn, J. J., Juzwin, K. R., Styer, D. M., & Aldridge, D. (2010). Measuring the urge to self-​injure: Preliminary data from a clinical sample. Psychiatry Research, 178, 540–​544. doi:10.1016/​j.psychres.2010.05.018 Whitlock, J., Muehlenkamp, J., Purington, A., Eckenrode, J., Barreira, P., Abrams, G. B., & Knox, K. (2011). Nonsuicidal self-​injury in a college population:  General trends and sex differences. Journal of American College Health, 59, 691–​698. doi:10.1080/​ 07448481.2010.529626.

Chapter 11

Addressing and Responding to Nonsuicidal Self-​I njury in the School Context Penelope Hasking, Imke Baetens, Elana Bloom, Nancy Heath, Stephen P. Lewis, Elizabeth Lloyd-​Richardson, and Kealagh Robinson Introduction Given the high rate of NSSI among adolescents, schools are an ideal environment for early detection and intervention. Schools, however, also pose unique challenges to addressing and responding to NSSI. With multiple stakeholders involved in student well-​ being (students, parents, teachers, administrators, mental health professionals), an effective response to NSSI in schools necessitates a whole-​school approach. With this in mind, there has been considerable growth in the development and evaluation of guidelines and protocols for schools (e.g., Berger, Hasking, & Reupert, 2014; Bubrick, Goodman, & Whitlock, 2010; Hasking et al., 2016). These protocols articulate a need for a qualified person, or team of people, for case management of students who self-​ injure. Yet, while these protocols provide some guidance on how to respond effectively, as well as the need for ongoing risk assessment, they often fail to address the more complex situations schools encounter. These include the role of school mental health professionals, when to involve families in the treatment of a student, how to manage social contagion within a school setting, and consideration of how NSSI is conceptualized in different cultures. In this chapter we draw on the most recent research, and our combined expertise in working with schools, to offer our thoughts on these complex situations. We conclude with three case studies that exemplify some of the complexities in addressing NSSI in schools and offer responses that optimize the well-​being of both the student and the school.

Supporting the Broader School Community The Role of School Mental Health Professionals The role of the school mental health professional (SMHP), such as a school​ guidance counsellor, school social worker, or school psychologist, in responding to NSSI is a uniquely challenging one, relative to that of mental health

176  Penelope Hasking et al.

professionals in community or hospital settings. This difficulty arises as a result of the many different roles the SMHP can have in responding to NSSI, largely dependent on the nature of the NSSI, and the reactions of the student. Below we include four common situations that might arise with a student who self-​injures. First, a student may be at low risk for suicide and willing to work with the school mental health professional, but resistant to outside referral or parent involvement. In this case, the school mental health professional will be the primary contact for the student. Regular counselling sessions, or participation in a prevention-​oriented group treatment, may be sufficient to monitor the student and provide ongoing support while teaching alternate coping strategies. Second, a student may have complex family circumstances, and/​or other mental health issues (e.g., eating disorder, substance abuse) requiring a range of outside services in collaboration with the SMHP. Here, it is imperative that the school has a clear system for inter-​agency involvement, and that the school mental health professional has productive collaborative relationships with outside mental health professionals. In complex cases, the outside professional is likely to be the primary source of treatment for the student. Clear communication between the SMHP, outside professionals, the student, and their parents (within the confines of confidentiality), while challenging, will be paramount to the student’s well-​being. Third, a student may be engaging in NSSI and may refuse any support from the SMHP or outside professional. In this situation, the SMHP will be required to work with the student in a collaborative and supportive manner to ensure that there is ongoing monitoring of the student for potential changes in their risk (including increasing NSSI severity, suicide risk, and risk of co-​occurring issues such as alcohol or drug use and eating disorders), as well as continued opportunities for the student to access services when ready. Finally, a student may be at high risk for suicide. In this case, the school would need to initiate immediate parent contact and hospitalization (in line with school policies). The SMHP would play a vital role in re-​integrating the student back into school when they are ready to return and providing ongoing support as required. These are just four examples of the roles SMHP can play  –​ranging from being the sole support for the student to liaising with multiple external agencies. The variation in how NSSI presents, the associated psychological morbidity, the attitudes of students, and the reaction of school staff and their families all converge to make the job of the SMHP extremely complex. Regardless of the situation, it is important that SMHP position the student’s well-​being as the number one priority, and work with all relevant stakeholders to achieve this goal. Engaging Parents/​G uardians One of the most common concerns schools have is when, and how, to tell parents/​ guardians that their child self-​ injures. Here, SMHP must balance a

NSSI in the School Context  177

student’s desire for confidentiality with the expectations of the parents, the welfare of the student, and any legal obligations of the profession. Ideally, parents would be involved in all cases where a student self-​injures. However, there are several factors that must be considered before deciding whether to contact parents, and how best to support the student. First, school staff must be mindful that the family environment could play a role in why a student is self-​injuring, or in maintaining the behavior. Second, it is important to be aware that NSSI affects not only the student, but also impacts parents, siblings, and family functioning. Thus, when and how parents are told of their child’s NSSI, and how they are supported, can directly impact the well-​being of the student who self-​injures. Family Environments and NSSI Various forms of child maltreatment (e.g., sexual abuse, neglect) and family conflict have been associated with NSSI, although these relations tend to be weak and can usually be better accounted for by other variables, such as self-​criticism, depressed mood, poor emotion regulation, and other intrapersonal factors (Asgeirsdottir, Sigfusdottir, Gudjonsson, & Sigurdsson, 2011; Baetens et al., 2015; Gandhi et al., 2016; Klonsky & Moyer, 2008; Swannell et al., 2012). A growing body of research demonstrates that the way adolescents perceive the family environment is associated with later NSSI (e.g., Tatnell, Kelada, Hasking, & Martin, 2014; Tatnell, Hasking, Newman, Taffe, & Martin, 2017). Perceptions of a lack of maternal trust, perceived lack of emotional support, parental criticism, parental over-​control, poor parental relationships, and poor family functioning have all been related to NSSI (Baetens et al., 2014, 2015; Di Pierro, Sarno, Perego, Gallucci, & Madeddu, 2012; Gandhi et  al., 2016; Kelada, Hasking, & Melvin, 2016; Tshan, Schmid, & In-​Albon, 2015). Few researchers have explored parent perceptions of family functioning, but those who have often find that the parent is unaware their child views family relationships unfavorably (Baetens et  al., 2014, 2015; Kelada, Whitlock, Hasking, & Melvin, 2016). Kelada and colleagues (2016) noted that parents only reported poor family functioning when they were aware of their child’s NSSI. This might explain why young people generally believe that solid family relationships are protective against NSSI, but those who self-​injure are less optimistic about the role parents can play in addressing NSSI (Berger, Hasking & Martin, 2013). However, while families might play a role in ongoing NSSI, it is important to bear in mind that parent support can buffer against potential risk factors such as bullying, victimization and depressed mood (Claes, Luyckx, Baetens,Van de Ven, & Witteman, 2015), and be a salient factor in cessation of NSSI (Tatnell et al., 2014). The Effect of NSSI on Parents and Families Although schools are most concerned about the welfare of the child and the school community, we cannot overlook the fact that NSSI has an impact on

178  Penelope Hasking et al.

parents and families (Crowell et al., 2008). Parents experience shock, fear, anxiety, self-​blame, and a range of other intense negative emotions when they learn of their child’s NSSI (Arbuthnott & Lewis, 2015; Kelada et al., 2016; Oldershaw, Richards, Simic, & Schmidt, 2008). Parenting practices also change in response to NSSI; parents report more controlling behaviors, increased monitoring of the child, and paying less attention to other children in the family, while also reporting that the experience can bring the family closer together (Baetens et al., 2015; Kelada et al., 2016). It is not uncommon for parents to report that they lack the requisite knowledge of NSSI, or how to interact with their child. Unsurprisingly, then, parents are keen for schools to offer more support, not just for their child, but for their own well-​being (Kelada et al., 2016; Kelada, Hasking & Melvin, 2017). Hence, there is a role for schools, and SMHPs, in educating and supporting parents, ensuring they have the resources and assistance available to help them care for their child, and practice self-​care. When and How to Involve Parents and Families With all this in mind, schools are in a tricky position when it comes to how best, and when, to inform families that their child self-​injures. Given the above considerations, there may be times when breaking confidentiality could confer additional risks to the child (e.g., in cases of abuse). Breaking confidentiality might increase an already heightened sense of alienation and a fear of their NSSI being discovered (White Kress, Costin, & Drouhard, 2006). Yet, involving parents is a salient predictor of cessation of NSSI, and effective parent–​child communication is critical to a child’s well-​being (Arbuthnott & Lewis, 2015; Kelada et al., 2016). As such, whether to notify parents warrants case-​ by-​ case consideration. It is important for SMHPs to have a sound understanding of the family dynamics before deciding whether to involve parents in the care of a student who self-​injures. When parents are informed of their child’s NSSI, SMHPs must be mindful that parents are also vulnerable in that situation (see above; Arbuthnott & Lewis, 2015). How the information is conveyed, and the support offered to parents, is critical in the long-​term outcome of the student. Another difficulty facing schools is who in the school is responsible for contacting parents in the first instance. In many cases the SMHP will have a more in-​depth understanding of NSSI, and the impact that disclosure can have on both students and their family. Arguably, they are best placed to disclose NSSI to parents, and to then work collaboratively with parents and students to achieve the best outcome for the student.Yet, in cases where acute medical attention is required, or where the student is unable to cope with the demands of school and time at home is recommended, the school principal may be required to contact parents. Potentially, this could lead to a situation where a parent who was previously unaware that their child self-​injures is confronted with this information, and further informed that their child is to be sent home. This disciplinary

NSSI in the School Context  179

approach to responding to NSSI is likely to exacerbate distress for both the student and families and leave everyone feeling unsupported. There are two ways to resolve this situation: (1) the SMHP and the principal contact parents together; or (2) schools adopt a two-​stage approach to contacting parents. If SMHP and principals jointly contact parents, this can demonstrate that everyone in the school is working collaboratively and are “on the same page” regarding the care of the student. However, this also raises the possibility that confidentiality is broken to a greater extent than is necessary (e.g., if the principal is privy to details of the NSSI). Alternatively, in a two-​stage approach, the SMHP contacts the parents to explain the current situation regarding the student’s NSSI and outlines the plans for care of the student. In this call, the SMHP informs the parent that the principal will be contacting them through a follow-​up phone call to explain any school-​level decisions regarding their child (e.g., attendance at school). In this way, the parents and students feel supported, and the call from the principal will not be unexpected. Clearly, in the event that a student expresses imminent risk for suicide, it is imperative to involve parents/​guardians. In these cases, the SMHP should be involved in the initial parent/​guardian contact (Toste & Heath, 2010), and immediate professional mental health care must be sought outside the school environment. In all cases, regardless of the urgency of the situation, we advise that when parents are informed of their child’s NSSI, that the student is involved in this process. The decision to contact the parents should be discussed with the student in advance, and students given the opportunity to provide input into the nature of this interaction. It is also important that students understand the extent and nature of the information that will be shared (e.g., merely alerting of general risk, details of NSSI, circumstances surrounding NSSI). Fundamentally, it is important to see youth as collaborators in the intervention process, giving choices about potential next steps and ensuring respectful language and demeanor (Walsh, 2012). Minimizing Social Contagion Schools offer an ideal environment in which to foster understanding of NSSI, reduce stigma, and provide students with the knowledge and skills to support each other. Although school-​based assemblies appear to be an attractive way to reach large numbers of students simultaneously, care needs to be taken in how NSSI is addressed at a school level. Of note, schools must be mindful of avoiding any potential to glamorize NSSI (e.g., discussing celebrities who self-​injure), using stigmatizing language (e.g., “self-​injurers,” “cutters”), ascribing unhelpful motives to NSSI (e.g., attention-​seeking behavior), or downplaying NSSI (e.g., saying most people “grow out of it”). Further, schools must be mindful of the potential for social contagion when discussing NSSI. “Social contagion” refers to the idea that awareness of NSSI, through peers, media, and/​or online, can promote or appear to encourage NSSI,

180  Penelope Hasking et al.

increasing risk for NSSI. Schools face a tension between the desire to educate and effectively support the entire school community (staff, parents, students), and the fear that doing so may actually increase the chance that students self-​ injure. We recommend that rather than discuss NSSI in detail, schools foster a broader discussion around healthy and unhealthy coping by students when faced with difficult or upsetting things in their lives, and the various coping strategies that students might use. In this way the NSSI is only mentioned in context with many other unhealthy coping strategies youth may use (e.g., anger outbursts, substance use, withdrawal) and there is not undue focus on the NSSI per se. Recognition that different coping strategies, both healthy and unhealthy, work for different people at different times, can help students and staff adopt a non-​ judgmental attitude toward students who self-​injure, while reducing the risk for social contagion. Schools commonly express concern for the potential for social contagion within peer groups, and through exposure to online material. While there is evidence that NSSI can exist within peer groups (Hasking, Andrews, & Martin, 2013; Jarvi, Jackson, Swenson, & Crawford, 2013; Prinstein et  al., 2010), and that exposure to NSSI in films and online is associated with more frequent NSSI (Radovic & Hasking, 2013), the most recent research paints a much more nuanced picture. Examination of NSSI in an online environment reveals both risks and benefits of online NSSI activities (Lewis & Seko, 2016). Recovery-​orientated websites can offer support and encouragement to young people attempting to cease their NSSI (Lewis & Seko, 2016; Swannell, Martin, Krysinska, & Win, 2010).Yet, many websites provide inaccurate and low-​quality information (Lewis, Michal, Mahdy, & Arbuthnott, 2014), while NSSI videos on YouTube, including ones which offer first aid tips, may reinforce the behavior (Lewis, Heath, St. Denis, & Noble, 2011; Lewis, Heath, Sornberger, & Arbuthnott, 2012; Lewis & Knoll, 2015). While reducing communication about NSSI is generally recommended in an effort to reduce social contagion (Nixon & Heath, 2009;Walsh, 2012), we cannot ignore the fact that NSSI is discussed in peer groups, online, and through social media. The question then becomes how to discuss NSSI without triggering vulnerable students. Schools have a role to play in explaining to students how explicit discussion of NSSI could be triggering for vulnerable students (Baker & Lewis, 2013; Lewis & Knoll, 2015). Following the same principles outlined above, students are encouraged to discuss the concerns underlying NSSI, rather than NSSI itself, avoiding explicit descriptions of specific acts of NSSI, especially detailed descriptions of methods or graphic images of NSSI. Responding to Students Showing Scars or Wounds When working with youth who self-​injure, school professionals may encounter situations in which students want to make the choice to no longer conceal injuries or scars that result from NSSI. Understandably, this can elicit worry that

NSSI in the School Context  181

vulnerable youth, namely those who self-​injure or who are at risk for NSSI, may see such displays and become triggered. The extent to which viewing injuries or scars affects NSSI urges or behavior represents a relatively new area of empirical inquiry. Nevertheless, there is at least some evidence that injuries and scars may differentially impact those who self-​injure. Specifically, triggering may be more salient when individuals who self-​injure view fresh NSSI wounds (Baker & Lewis, 2013; Lewis & Baker, 2011). While learning to effectively manage triggering situations can be a valid therapeutic goal, viewing NSSI scars may not be as triggering (Baker & Lewis, 2013). Further, there is growing evidence that, for many individuals, coming to terms with and accepting NSSI scars constitutes a key part of recovery; for some, this involves choosing to reveal their scars (Lewis & Mehrabkhani, 2016; Lewis, 2016). Indeed, choosing to no longer hide NSSI scars can be especially therapeutic as it helps to alleviate the shame and stigma associated with having self-​injured (Lewis, 2016). This potential benefit to the student with a history of NSSI needs to be balanced against the low risk of harm to those at risk for being triggered, and to those students who may be uncomfortable with seeing scars. Although research in this area is in its early stages, we offer the following recommendations. For cases in which a student wishes to display NSSI wounds, school personnel should adopt a framing akin to the management of any open wound. That is, students should be asked to cover their wounds, due to school health requirements concerning potential contamination by blood, as would be the case for any cut or injury. Additionally, it is important to be sensitive to the reason(s) students have for wanting to show their wounds (e.g., to combat stigma). These reasons should be validated while explaining to the student that there is evidence suggesting that others who struggle with NSSI may be inadvertently triggered by seeing others’ wounds and that there is school policy concerning any open wound. A different approach should be adopted for scarring. Requiring students to conceal their NSSI scars may invalidate their recovery efforts and engender a sense of shame about having self-​injured. Hence, it should be acknowledged that, for some, the decision to reveal their scars can represent a major step in their recovery journey (Lewis, 2016; Lewis & Mehrabkhani, 2016). At the same time, it is essential that students who are ready to show their scars be aware that this may carry unintended consequences. For instance, showing one’s scars may provoke intrusive (and unwanted) questions, adverse reactions (e.g., negative comments), or even teasing and bullying. Accordingly, when interacting with students about NSSI scars, school mental health professionals should adopt a validating, compassionate, and sensitive approach. Such conversations should include: (a) recognition that the choice to display one’s scars is ultimately that of the student, (b) acknowledgment that no longer hiding one’s scars may be a key step in the student’s recovery; and (c) dialogue about the potential negative consequences of displaying NSSI scars, with careful attention to how potential challenges can be mitigated, including how the student can be supported.

182  Penelope Hasking et al.

Diverse School Environments Diverse school environments include settings beyond the classroom walls in which non-​custodial caregivers are responsible for the safety and well-​being of students. These include boarding schools, study-​abroad programs, and sleepaway camps, as well as educational settings in hospitals or residential care settings. Responding to NSSI among students in these diverse school environments poses unique challenges that warrant consideration. The structural makeup of these environments may increase the risk of NSSI. Programs often involve a number of transitions, such as being uprooted from regular peer groups and support systems, meeting many new people, and creating new daily routines and expectations (Bramston & Patrick, 2007), all of which may be distressing to some young people, and result in more NSSI. Programs are often shorter than the school year, resulting in shorter timeframes to establish therapeutic relationships and to identify patterns in concerning thoughts and behaviors. Challenges may also arise with a lack of continuity of care between the young person’s primary mental health professional, SMHPs, and other pastoral care providers (e.g., school chaplains, pastor), as well as poor communication between the family system and staff about past experiences of NSSI. Additional limitations may arise when mental health information becomes siloed in different sectors of the program, such as instances where night-​shift residential care staff experience barriers to efficient clinical handover regarding the young person’s night-​time behavior to day-​shift mental health professionals (Hunt, Marsden, & O’Connor, 2012). To help mitigate these structural factors, we encourage schools and other diverse educational settings and SMHPs to obtain comprehensive mental health background information alongside the physical health evaluations typically provided during enrolment. The unique social environment of diverse school environments provides additional considerations for addressing NSSI. Dormitory-​ style sleeping arrangements, communal showering, or an emphasis on swimming and water-​ based activities may make recent NSSI wounds and scars more noticeable to other students and staff. As within all school environments, staff should be aware of the school’s protocol for addressing NSSI in order to mitigate diffusion of responsibility and appropriate care.This training may be particularly pertinent in settings where similar-​aged peer mentors form close relationships with students (Lyons, 2003), and who themselves may have a personal experience with NSSI. Peer counsellors/​ mentors typically undergo training before embarking on school camps or other off-​campus settings. We suggest this training include discussion of NSSI, including how to identify NSSI, and how to respond to students who self-​injure. Mental health staff can keep in mind that the close peer relationships which often develop in environments such as summer camps (Bialeschki, Henderson, & James, 2007) may increase the risk for social contagion (Jarvi et al., 2013). Staff should ensure that systems are in place in these non-​ traditional environments to support the friends of young people who self-​injure.

NSSI in the School Context  183

Diverse school environments also have the ability to foster protective factors and resiliencies among students. Nature-​based environments may act as catalyst for mood improvements (Berman et al., 2012) as well as respite from stressors such as social media. Over the course of programs such as summer camp, young people can establish meaningful relationships with mentors and peers (Bialeschki, Henderson, & James, 2007; Lyons, 2003), as well as increased self-​ esteem (Readdick & Schaller, 2005) and socioemotional competencies (Ee & Ong, 2014; Thurber, Scanlin, Scheuler, & Henderson, 2007). NSSI in Elementary School Another consideration concerning the school environment is whether the student is in elementary or secondary school. The vast majority of research is conducted with secondary school students, and it is from this research we draw our recommendations. However, when we ask adolescents when they first self-​ injured, it is not uncommon for the age of onset to be quite young (Barrocas, Hankin, Young, & Abela, 2012). Further, we are increasingly hearing anecdotal reports of elementary school students who self-​injure. Given the lack of research, we do not have empirical data on the rates of NSSI in younger students, the functions the behavior serves for these children, or where they first obtain the idea to self-​injure. We also do not know how elementary school teachers, or other staff, might think about or react to NSSI in the elementary school context, where there might arguably be less of a focus on social–​emotional learning than there is in secondary schools. Further work on the nature and extent of NSSI in elementary school students, and the developmentally appropriate way to respond to young students who self-​injure, is needed.

Cultural Considerations There is very little research into how NSSI is conceptualized in different cultures. The little research available suggests that school staff should be mindful that the way they view NSSI may not be how a student from another culture views the behavior. For example, although the primary function of NSSI in western cultures is affect regulation, social reasons are more prominent in eastern countries (Gholamrezaei, De Stefano, & Heath, 2017). Adolescents in Hong Kong are more likely to use NSSI to regulate interpersonal issues than to regulate negative emotions (You, Leung, & Fu, 2012), while among university students in India, minor forms of NSSI are used to regulate social situations while more severe NSSI serves an affect-​regulatory function (Kharsati & Bhola, 2014). Gholamrezaei, Heath, and Panaghi (2017) observed that more than half of university students in their Iranian sample reported engaging in NSSI behavior in the presence of others, suggesting a more social function; the relation between emotion regulation and NSSI was weaker than typically observed in western countries. Reasons for these cultural differences have not

184  Penelope Hasking et al.

been explored. Arguably different attitudes toward suicidal behavior and mental health, and whether a culture is individualistic or collectivist, could each inform the nature and extent of NSSI. Religion may also play a role in how NSSI is expressed. Religious beliefs appear protective against NSSI (Gholamrezaei et al., 2017); however, feeling abandoned or ignored by God or a higher power during times of stress is related to an increased risk of NSSI (Buser, Buser, & Rutt, 2017). One final thought regarding cross-​ cultural considerations bears mention. While the nature, extent, and expression of NSSI can vary, the response to NSSI also varies across countries. Although yet to be investigated, countries in which suicide is illegal may approach NSSI from a disciplinary, rather than welfare-​ centered, approach. A disciplinary approach to NSSI is not uncommon in school policies, with students asked to remain at home until wounds heal. We would argue that every effort should be made to keep students at school and that exclusion should only be considered as a last resort, when there are immediate safety concerns, and/​or when a student does not have the capacity to cope with the demands of school. The legal requirements of teachers, principals, and school mental health professionals to report NSSI to parents also varies across, and within, countries. This can create friction within a school environment if teachers are legally required to report such behavior, but school mental health staff are not. Finally, the tension between confidentiality and duty of care can vary across countries and depending on a student’s age. For example, in Canada confidentiality must be maintained if a student is 14 years or older, while in the U.S.A., students might reasonably expect that parents are informed of any self-​ harming behavior until the age of 18. In all cases, students should be informed of the limits of confidentiality early in the treatment process.

Case Studies Below, we present three case studies that highlight some of the issues identified above, or in other chapters of this book. In each case we have presented three potential responses that could reasonably be expected to occur in a school setting, and which may result in detrimental outcomes for the student and the school. We conclude each case study with a more appropriate response that, in these hypothetical situations, produces an optimal outcome. The Case of Tiffany Tiffany is a 15-​year old in the ninth grade at a prestigious high school in Canada. She is an excellent student. She is very driven and perfectionistic and frequently gives herself a hard time if she doesn’t meet the high standards she has set for herself. Tiffany uses self-​injury to help herself focus on her school work, but lately she has had to do more and more of it in order to maintain her high level of concentration. She recently told a friend, Maria, how helpful cutting has been for

NSSI in the School Context  185

her. Maria tried cutting, but had a very different experience with self-​injury, and felt rather traumatized by it. Maria’s parents found out about her cutting and told the school about how Tiffany had encouraged Maria to experiment with self-​ injury. Tiffany was brought into the counselor’s office for questioning and was quite defensive, stating “I’m doing really well; I’m a straight A student, I’m not suicidal, so leave me alone.” The school counselor tried to walk her through the idea that the self-​injury may become progressive, with Tiffany needing to engage in it more often to get the same effect.Tiffany refused to involve her parents and, given that she was over the age of consent, the school couldn’t legally require her to include them in the conversation.The counselor was feeling frustrated because she felt that Tiffany was spiraling and didn’t know how to proceed with getting her involved in treatment. The Principal really wanted something done; he was not OK with Tiffany refusing treatment and refusing to inform her parents. Identified Issues • •• ••

•

Maria is prompted to try NSSI after learning about Tiffany’s behavior. Contagion among peer groups can, and does, happen Escalating severity of NSSI increases subsequent suicide risk In Canada, once a student reaches 14 years of age, the school mental health professional must maintain confidentiality and not disclose NSSI to the parents. Legislation around reporting requirements differs across, and within, countries Tiffany refuses treatment, putting the school counselor into an uncomfortable situation

Common Responses Response 1. Out of concern for Tiffany, the Principal puts pressure on the counselor to try to “strongly encourage” and push her forward with treatment and stopping self-​injury. The counselor perceived that her conversations with Tiffany were an attempt to “motivate her to change,” pushing Tiffany to consider the physical consequences of her self-​injury. This led Tiffany to respond defensively by saying such things as “you have no idea what you are talking about.” Tiffany continued to refuse treatment. Response 2. The administration sent out a school-​wide letter that is vaguely worded about a student engaging in self-​injury at school and encouraging parents to talk with their teens about this. The Principal bypassed all of the normal school procedures and went straight to Tiffany’s parents. He insisted that the parents get their child help and wanted documentation that Tiffany was being treated by a counselor outside of the school. This put the parents in a significant bind, as this was all brand-​new information to them and they were not sure where to reach out for assistance, or whether she would even agree to seeing someone.

186  Penelope Hasking et al.

Response 3. Tiffany insisted that she was “fine” and refused treatment.The school counselor and administrators realize that she was over the age of consent and they were not legally responsible for mandating treatment. They asked her to document that she was refusing treatment. They documented that a suicide risk assessment had been done. The counselor and administrators felt that their hands had been tied, feeling frustration, helplessness, and some degree of resentment or anger that this young person was unwilling to accept the support she clearly needed.

Best Practice Exemplified It is important for the school counselor to acknowledge that it is Tiffany’s decision and she is free to refuse treatment. The counselor should talk with the student about their concerns for her, provide information about self-​injury, and aim to validate and acknowledge Tiffany’s own experience of self-​injury and what it does for her. The counselor should suggest that they get together occasionally to talk –​not about NSSI –​but about various ways that Tiffany may benefit from managing stressful times. In this situation, it would be helpful to make the conversation about stress management and performance enhancement, which are both important to Tiffany. This puts Tiffany in the mode of maximizing performance and less about illness and how the self-​injury is unhelpful.Then, as the counselor’s relationship develops with Tiffany, self-​injury can be brought to the table in a less threatening way.This approach also allows the counselor and Tiffany to develop a working relationship that may feel more comfortable for Tiffany. This will allow the counselor to assess any changes in Tiffany’s experiences with self-​injury, and whether these have led her mood to change or worsen. While Tiffany isn’t presently suicidal, it is still important to be aware of potential changes in her mood that may lead her to be vulnerable to suicidal thoughts. It is also important to be completely open with Tiffany about the issue of Maria’s parents (and therefore other school parents), knowing unfortunately that they are aware of Tiffany’s self-​injury. While the administration may feel as though they are responsible and need to move quickly forward with informing Tiffany’s parents specifically, and the school community more generally, they must recognize the significant psychological and familial consequences of doing so. In this situation, we would encourage Tiffany to talk to her parents, with the counselor’s support, in order to avoid her parents hearing about Tiffany’s self-​injury from others.The administration should be encouraged to remind Maria’s parents when they initially called the school that they are expected to maintain Tiffany’s privacy. The Case of Tarek Tarek is a 12-​year-​old boy who is overweight, a talented artist and writer, quiet and sensitive. He is not athletic and has a long history of being bullied.

NSSI in the School Context  187

When he moved to the seventh grade and a new school, he became separated from his peer group and was left with no close friends. He chose to spend his free time in the library, writing poetry. Bullying escalated during this time and became quite harsh. He worked very hard to avoid conflict, but after being pushed and pushed, he would periodically explode in angry outbursts. During his seventh-​ g rade year, several bullies destroyed the contents of his locker. Tarek became so enraged that he punched a concrete wall and bloodied his fist, needing to go to the school nurse to have it bandaged. He reported learning from this experience that it was better to hit a wall and hurt himself rather than take out his aggression on someone else and get into trouble. Further, he found that he appreciated the care and support he received from the school nurse for his injuries. He continued to hit walls when he was frustrated or angry, and eventually began to burn himself with cigarettes in order to get the same relief from his loneliness, frustration, and anger. His self-​injury escalated and became more severe over the course of the next year. After a gym class one day, Tarek was pulled out of the shower by several of the boys that regularly bullied him. They noticed cigarette burns on his arms and chest and expressed disgust at seeing this. The boys took a picture of Tarek in the shower and shared this via social media, the image quickly spreading around the school. One of the boys felt badly and was concerned for Tarek, so he confided in the gym teacher, Mr. Block, about Tarek’s burns. Following the locker room incident, Tarek’s behavior escalated and he made a suicide attempt by making deep cuts on his wrists, requiring hospitalization. Identified Issues • •• •• •

In school-​based samples, self-​injury is just as common among boys as it is among girls. However, boys are more likely to engage in self-​battery than girls Stigma associated with NSSI can be exacerbated in boys. How NSSI is discussed and treated among the student body is important to address Bullying and social isolation increase risk of NSSI and suicide Escalation of NSSI severity is a risk factor for subsequent suicidal thoughts and behavior

Common Responses Response 1. When Mr. Block first learned about Tarek’s burns, he approached Tarek and expressed concern for him. Mr. Block had helped Tarek in the past with physical activity training and believed he had a close relationship with Tarek. Tarek was clearly shaken by the events and asked Mr. Block to not tell anyone about the situation. Mr. Block promised that he would keep this between the two of them. However, Mr. Block soon realized he was in over his head and he went to the school counselor to inform her

188  Penelope Hasking et al.

of the situation. He never told Tarek that he was “going behind his back.” Tarek felt betrayed, leading to further escalation of his feelings. Tarek felt so humiliated that he attempted suicide. Response 2. Mr. Block doesn’t talk with Tarek right away. Instead, he opts to contact the school counselor. She is not in the office until Friday of that week, so in the meantime, Mr. Block asks other teachers in the school if they are aware of what is going on with Tarek, trying to gather additional information and formulate a “best approach” to the situation. Response 3. Mr. Block tells the administrator about Tarek and the administrator calls Tarek into the office. Using a “man-​to-​man tone,” the administrator doesn’t recognize Tarek’s burns as self-​injury and assumes that the burns are something that someone has done to Tarek, or perhaps that Tarek has done these out of a dare, in order to “be tough.” Tarek finds it too difficult to admit the real reasons for his self-​injury, and simply agrees with the administrator that he has been doing this because of a dare. Best Practice Exemplified As soon as Mr. Block hears about this, he should immediately go to the school’s mental health professional to discuss. If that person isn’t available, then he should seek out the designated point person in order to share what has happened. That person will then pull Tarek out of class to offer support and assess the situation further. Tarek responds to this with relief and is able to share how bad it has been for him and he is willing to receive help. The school mental health professional should discuss with Tarek the need for involving his parents and provide ongoing monitoring and support. Suicide risk assessment should be conducted on the same day and should identify Tarek’s high risk for suicide and he would then be taken for additional services. For boys, there is particularly heightened social stigma associated with self-​injury and the counselor needs to recognize, acknowledge, and proactively manage this with Tarek and his family. Separately, the boys involved in the shower incident need to be pulled in for discussion with appropriate school staff, taking care to be mindful of confidentiality surrounding the specifics of Tarek’s situation. The Case of Lin Lin is a 17-​year-​old of Asian descent, in her last year of high school. She has a long history of self-​injuring and appears defiant and angry at school. She began cutting her skin when she was 12 years old. Lin’s parents first heard about her self-​injury from her sister. Her parents took her to a psychiatrist for a short time to “try and fix her” and the family never talked about it again, despite it remaining an ongoing activity. The psychiatrist said that Lin’s wounds were “superficial” and merely attempts to get attention. She openly flaunts her “battle scars” on her arms and legs, declaring to students and staff, “you don’t know

NSSI in the School Context  189

me and what I’ve been through.” On the first warm day of the year, Lin shows up at school wearing short sleeves, leading both students and staff to talk about this and cause an uproar at school. Lin was sent to the school counselor’s office and declared, “No one knows what it’s like to be in my family, to be in my culture.” Self-​injury serves a great purpose for her and allows her an outlet for self-​expression. “In my family, the self-​injury doesn’t exist. No one talks about self-​injury scars or wounds; silence is a common response.” Lin has learned that no one, not even other family members, can know about her mental health struggles or self-​injury because that would bring shame on her whole family. Identified Issues • •• •

There is some evidence that NSSI is viewed differently by different cultures, just as attitudes to mental illness vary across cultures Negative attitudes held by health professionals diminish rapport and reduce future help-​seeking By openly displaying wounds and scars –​and flaunting them –​Lin may be putting vulnerable students at risk of NSSI

Common Responses Response 1. The school counselor insists on Lin covering her scars before she is allowed to return to school. Lin perceives this as being “censored” and she responds with anger, refusing to return to school. The school and Lin are at a stand-​off. Response 2.  Lin’s wounds are perceived by school administrators and staff as misguided efforts to gain attention. Staff and students are told to ignore Lin’s “attention-​getting behavior” in an effort to get Lin to stop cutting. This only leads Lin to cut more, until it escalates so much that Lin is cutting in class. Response 3. The school principal who has become involved expresses to the school team her belief that Lin’s behavior is a result of the intense pressure she feels from her Asian family to perform and excel. This bias results in the principal reaching out to the family unilaterally to express concerns that Lin needs less pressure, leading to the family withdrawing Lin from the school and moving to another school. Lin’s self-​injury is never addressed. Best Practice Exemplified First, steps must be taken to work towards collaborating with Lin. This means meeting with her to validate that these are battle scars and can be a sign of strength that she is willing to show these scars. However, it is also important to discuss with her that fresh wounds can be triggering to other people and that health-​wise, contamination with blood is a real concern in school. It would also

190  Penelope Hasking et al.

be important for the school counselor to talk with Lin about her interest and willingness to meet with an outside counselor in order to help her with sorting out her struggles. Second, the counselor will want to work with Lin to persuade her of the benefits of sharing the situation with her family to obtain needed family support. The counselor will need to take a culturally sensitive approach with Lin’s family in order to educate them that NSSI is viewed differently in this culture and shouldn’t be ignored, acknowledging the role that shame may have played in contributing to how they have responded to Lin’s actions. The counselor should approach Lin’s parents and try to get their perspective on this behavior; identify a middle ground for helping this student, recognizing the cultural constraints.Third, there will need to be a school-​wide response as well.This school-​wide response should be embedded within a regularly scheduled assembly or morning meeting alongside the normal business of the day, with the primary goals of normalizing, contextualizing, and giving guidelines. For instance, school administrators should consider talking with the whole school about being a supportive community, perhaps setting the following tone:  Different people have had different issues and difficulties in their lives, sometimes coping in healthy ways and sometimes coping in unhealthy ways (e.g., angry responses, substance abuse, physical injury to manage internal pain).While we may each deal with our own difficulties in many ways, we still need to offer support and avoid judging each other. Ask students to consider how they can each best support one another. Remind students: Do not judge, do not ask intrusive questions, be respectful of others. If they have concerns about a friend, talk with them and tell them you’re concerned about them and ask if they want to talk about it. If they have questions or concerns, they should see the school’s mental health point-​person.

Conclusion Despite increasing concern among school staff regarding NSSI among students, there are few clear guidelines to assist staff. Local legislation, education department policies, and cultural considerations will necessarily drive implementation of such guidelines. At the very least, we suggest discussion concerning the development of an explicit and clearly communicated school protocol, training for all staff regarding NSSI, and consideration of the complexities concerning efforts to minimize contagion of NSSI in the school context is essential for all schools wishing to respond effectively to NSSI.

Useful Resources Websites http://​sioutreach.org/​ www.selfinjury.bctr.cornell.edu/​ www.self-​injury.org.au/​ www.zelfverwonding.be

NSSI in the School Context  191 www.zelfbeschadiging.nl www.mentalhealth.org.nz/​get-​help/​a-​z/​resource/​49/​self-​harm http://​youthwellbeingstudy.wordpress.com

Policies and Protocols Berger, E., Hasking, P., & Reupert, A. (2014). Guidelines for responding to non-​suicidal self-​ injury in schools. Monash University. Includes policy and flowchart. Available at www. self-​injury.org.au/​ Bubrick, K., Goodman, J., & Whitlock, J. (2010). Non-​suicidal self-​injury in schools: Developing and implementing school protocol. Cornell Research Program on Self-​Injurious Behavior in Adolescents and Young Adults. Available at www.selfinjury.bctr.cornell.edu/​ documents/​schools.pdf. Hasking, P., Heath, N. L., Kaess, M., Lewis, S. P., Plener, P. L., Walsh, B. W., Whitlock, J., & Wilson, M. S. (2016). Position paper for guiding response to non-​suicidal self-​injury in schools. School Psychology International, 37, 644–​663.

Online Training www.selfinjury.bctr.cornell.edu/​training.html

Self-​H elp Booklets Martin, G., Hasking, P., Swannell, S., Lee, M., McAllister, M., & Greisbach, K. (2013). Seeking solutions to self-​injury, 2nd edition. Brisbane: Centre for Suicide Prevention Studies, The University of Queensland, Brisbane. Applicable to school staff: www.familyconcernpublishing.com.au/ ​ p roduct/ ​ s eekingsolutions-​ t o-​ s elf-​ i njurythe-​school-​staff-​guide-​2nd-​edition/​ Applicable to families: www.familyconcernpublishing.com.au/​product/​seekingsolutions-​ to-​self-​injury-​the​parents-​and-​families-​guide-​2nd-​edition/​ Applicable to youth: www.familyconcernpublishing.com.au/​ p roduct/​ s eeking-​ s olutions-​ t o-​ s elf-​ i njury​the-​young-​peoples-​guide/​

References Arbuthnott, A. E. & Lewis, S. P. (2015). Parents of youth who self-​injure: A review of the literature and implications for mental health professionals. Child and Adolescent Psychiatry and Mental Health, 9:35. Asgeirsdottir, B.  B., Sigfusdottir, I.  D., Gudjonsson, G.  H., & Sigurdsson, J.  F. (2011). Associations between sexual abuse and family conflict/​ violence, self-​ injurious behavior, and substance use: The mediating role of depressed mood and anger. Child Abuse & Neglect, 35, 210–​219. Baetens, I., Claes, L., Hasking, P., Smits, D., Grietens, H., Onghena, P., & Martin, G. (2015). The relationship between parental expressed emotions and NSSI: The mediating roles of self-​criticism and depression. Journal of Child and Family Studies, 24, 491–​498.

192  Penelope Hasking et al. Baetens, I., Claes, L., Martin, G., Onghena, P., Grietens, H.,Van Leeuwen, K., … Griffith, J.W. (2014). Is nonsuicidal self-​injury associated with parenting and family factors? Journal of Early Adolescence, 34, 387–​405. Baetens, I., Claes, L., Onghena, P., Grietens, H.,Van Leeuwen, K., Pieters, C., … Griffith, J.W. (2015). The effects of nonsuicidal self-​injury on parenting behaviors: A longitudinal analyses of the perspective of the parent. Child & Adolescent Psychiatry and Mental Health, 9, 24. Baetens, I., Claes, L., Onghena, P., Grietens, H.,Van Leeuwen, K., Pieters, C., … Griffith, J.W. (2014). Non-​suicidal self-​injury in adolescence: A longitudinal study of the relationship between NSSI, psychological distress and perceived parenting. Journal of Adolescence, 37, 817–​823. Baker, T. G. & Lewis, S. P. (2013). Responses to online photographs of non-​suicidal self-​ injury: A thematic analysis. Archives of Suicide Research, 17, 223–​235. Barrocas, A. L., Hankin, B. L.,Young, J. F., & Abela, J. R. (2012). Rates of nonsuicidal self-​ injury in youth: age, sex, and behavioral methods in a community sample. Pediatrics, 130(1),  39–​45. Berman, M.  G., Kross, E., Krpan, K.  M., Askren, M.  K., Burson, A., Deldin, P.  J., … Jonides, J. (2012). Interacting with nature improves cognition and affect for individuals with depression. Journal of Affective Disorders, 140, 300–​305. Berger, E., Hasking, P., & Martin, G. (2013). “Listen to them”:  Adolescents’ views on helping young people who self-​ injure. Journal of Adolescence, 36(5), 935–​ 945. doi:10.1016/​j.adolesence.2013.07.011 Berger, E., Hasking, P., & Martin, G. (2017). Adolescents’ perspectives of youth non-​ suicidal self-​injury prevention. Youth and Society, 49, 3–​22 Bialeschki, M. D., Henderson, K. A., & James, P. A. (2007). Camp experiences and developmental outcomes for youth. Child and Adolescent Psychiatric Clinics of North America, 16, 769–​788. Bramston, P. & Patrick, J. (2007). Rural adolescents experiencing an urban transition. Australian Journal of Rural Health, 15, 247–​251. Buser, J. K., Buser, T. J., & Rutt, C. C. (2017). Nonsuicidal self-​injury and spiritual/​religious coping. Journal of Mental Health Counseling, 39, 132–​148. Claes, L., Luyckx, K., Baetens, I., Van de Ven, M., & Witteman, C. (2015). Bullying and victimisation, depressed mood, and non-​suicidal self-​injury in adolescents: The moderating role of parental support. Journal of Child & Family Studies, 24, 3363–​3371. Crowell, S. E., Beauchaine, T. P., McCauley, E., Smith, C.,Vasilev, C. A., & Stevens, A. L. (2008). Parent–​ child interactions, peripheral serotonin and self-​ inflicted injury in adolescents. Journal of Consulting & Clinical Psychology, 76, 15–​21. Di Pierro, R., Sarno, I., Perego, S., Gallucci, M., & Madeddu, F. (2012). Adolescent nonsuicidal self-​injury: The effects of personality traits, family relationships and maltreatment on the presence and severity of behaviors. European Child & Adolescent Psychiatry, 21, 511–​520. Ee, J., & Ong, C.  W. (2014). Which social emotional competencies are enhanced at a social emotional learning camp? Journal of Adventure Education and Outdoor Learning, 14,  24–​41. Gandhi, A., Claes, L., Bosmans, G., Baetens, I., Wilderjans, T.F., Maitra, S., … Luyckx, K. (2016). Non-​suicidal self-​injury and adolescents’ attachment with peers and mother: The mediating role of identity synthesis and confusion. Journal of Child & Family Studies, 25, 1735–​1745.

NSSI in the School Context  193 Gholamrezaei, M., De Stefano, J., & Heath, N. L. (2017). Nonsuicidal self-​injury across cultures and ethnic and racial minorities: A review. International Journal of Psychology, 52, 316–​326. Gholamrezaei, M., Heath, N.  L., & Panaghi, L. (2017). Non-​suicidal self-​injury in a sample of university students in Tehran, Iran:  Prevalence, characteristics and risk factors. International Journal of Culture and Mental Health, 10, 136–​149. Hasking, P., Andrews, T., & Martin, G. (2013). The role of exposure to self-​injury among peers in predicting later self-​injury. Journal of Youth and Adolescence, 42, 1543–​1556. Hasking, P., Heath, N. L., Kaess, M., Lewis, S. P., Plener, P. L., Walsh, B. W., … Wilson, M. S. (2016). Position paper for guiding response to non-​suicidal self-​injury in schools. School Psychology International, 37, 644–​663. Hunt, G. E., Marsden, R., & O’Connor, N. (2012). Clinical handover in acute psychiatric and community mental health settings. Journal of Psychiatric and Mental Health Nursing, 19, 310–​318. Jarvi, S., Jackson, B., Swenson, L., & Crawford, H. (2013). The impact of social contagion on non-​suicidal self-​injury: A review of the literature. Archives of Suicide Research, 17,  1–​19. Kelada, L., Hasking, P., & Melvin, G. (2016). The relationship between nonsuicidal self-​ injury and family functioning: Adolescent and parent perspectives. Journal of Marital and Family Therapy, 42, 536–​549. Kelada, L., Hasking, P., & Melvin, G. (2017). School response to self-​injury: Concerns of mental health staff and parents. School Psychology Quarterly, 32, 173–​187. Kelada, L., Whitlock, J., Hasking, P., & Melvin, G. (2016). Parents’ experiences of nonsuicidal self-​injury among adolescents and young adults. Journal of Child and Family Studies, 25, 3403–​3416. Kharsati, N., & Bhola, P. (2014). Patterns of non-​suicidal self-​injurious behaviors among college students in India. International Journal of Social Psychiatry, 61(1), 39–​49. Klonsky, E.  D., & Moyer, A. (2008) Childhood sexual abuse and non-​suicidal self-​ injury: Meta-​analysis. British Journal of Psychiatry, 192, 166–​170. Lewis, S. P. (2016).The overlooked role of self-​injury scars: A commentary and suggestions for clinical practice. Journal of Nervous & Mental Disease, 204, 33–​35. Lewis, S. P. & Baker, T. (2011). The possible risks of self-​injury websites: A content analysis. Archives of Suicide Research, 15, 390–​396. Lewis, S.  P., Heath, N.  L., Sornberger, M.  J., & Arbuthnott, A.  E. (2012). Helpful or harmful? An examination of viewers’ responses to non-​suicidal self-​injury videos on YouTube. Journal of Adolescent Health, 51, 380–​385. Lewis, S. P., Heath, N. L., St. Denis, J. M., & Noble, R. (2011). The scope of non-​suicidal self-​injury on YouTube. Pediatrics, 127, e552–​557. Lewis, S. P. & Knoll, A. (2015). Do it yourself: Examination of self-​injury first aid tips on YouTube. Cyberpsychology, Behavior, & Social Networking, 18, 301–​304. Lewis, S. P. & Mehrabkhani, S. (2016). Every scar tells a story: Insight into people’s self-​ injury scar experiences. Counselling Psychology Quarterly, 29, 296–​310. Lewis, S. P., Michal, N. J., Mahdy, J., & Arbuthnott, A. E. (2014). Googling self-​injury: The state of health information obtained through online searches for self-​injury. JAMA Pediatrics, 168, 443–​449. Lewis, S. P., & Seko, Y. (2016). A double-​edged sword: A review of benefits and risks of online nonsuicidal self-​injury activities. Journal of Clinical Psychology, 72, 249–​262.

194  Penelope Hasking et al. Lyons, K. D. (2003). Exploring the meanings of community among summer camp staff. World Leisure Journal, 45, 55–​61. Nixon, M. K. & Heath, N. L. (2009). Self-​injury in youth: The essential guide to assessment and intervention. New York: Routledge Press. Oldershaw, A., Richards, C., Simic, M., & Schmidt, U. (2008). Parents’ perspectives on adolescent self-​harm:  Qualitative study. The British Journal of Psychiatry, 193, 140–​144. Prinstein, M., Heilbron, N., Guerry, J., Franklin, J. C., Rancourt, D., Simon,V., & Spirito, A. (2010). Peer influence and nonsuicidal self-​injury: Longitudinal results in community and clinically-​referred adolescent samples. Journal of Abnormal Child Psychology, 38, 669–​682. Radovic, S. & Hasking, P. (2013).The relationship between film portrayals of non-​suicidal self-​injury, attitudes, knowledge and behavior. Crisis, 34, 324–​334. Readdick, C. A. & Schaller, G. R. (2005). Summer camp and self-​esteem of school-​age inner-​city children. Perceptual and Motor Skills, 101, 121–​130. Swannell, S., Martin, G., Krysinska, K., & Win, L. (2010). Cutting on-​line: Self-​injury and the internet. Advances in Mental Health, 9, 177–​189. Swannell, S., Martin, G., Page, A., Hasking, P., Hazell, P., Taylor, A., & Protani, M. (2012). Child maltreatment, subsequent non-​suicidal self-​injury and the mediating roles of dissociation, alexithymia and self-​blame. Child Abuse & Neglect, 36, 572–​584. Tatnell, R., Kelada, L., Hasking, P., & Martin, G. (2014). Longitudinal analysis of adolescent NSSI: The role of intrapersonal and interpersonal factors. Journal of Abnormal Child Psychology, 42, 885–​896. Tatnell, R.  C., Hasking, P., Newman, L., Taffe, J., & Martin, G. (2017). Attachment, emotion regulation, childhood abuse and assault:  Examining predictors of NSSI among adolescents. Archives of Suicide Research, 17, 610–​620. Thurber, C. A., Scanlin, M. M., Scheuler, L., & Henderson, K. A. (2007). Youth development outcomes of the camp experience:  Evidence for multidimensional growth. Journal of Youth and Adolescence, 36, 241–​254. Toste, J.  R. & Heath, N.  L. (2010). School response to non-​suicidal self-​injury. The Prevention Researcher, 17, 14–​17. Tshan, T., Schmid, M., & In-​Albon, T. (2015). Parenting behavior in families of female adolescents with nonsuicidal self-​injury in comparison to a clinical and a nonclinical control group. Child & Adolescent Psychiatry & Mental Health, 9, 17. You, J., Leung, F., & Fu, K. (2012). Exploring the reciprocal relations between nonsuicidal self-​injury, negative emotions and relationship problems in Chinese adolescents:  A longitudinal cross-​lag study. Journal of Abnormal Child Psychology, 40, 829–​836. Walsh, B.  W. (2012). Treating self-​injury:  A practical guide, 2nd edition. New  York:  The Guilford Press. White Kress, V. E., Costin, A., & Drouhard, N. (2006). Students who self-​injure: School counsellor ethical and legal considerations. Professional School Counselling, 10, 203–​209.

Chapter 12

Toward an Understanding of Online Self-​I njury Activity Review and Recommendations for Researchers and Clinicians Stephen P. Lewis,Therese E. Kenny, and Tyler R. Pritchard Introduction Technological advances and increases in accessibility to devices with internet access over the past decade have contributed to ubiquitous use of online platforms as a primary method of communication and information sharing (Perrin, 2015; Poushter, 2016). Recently, the online activity of individuals who engage in nonsuicidal self-​injury (NSSI) has emerged as a cardinal area of interest and concern for researchers and mental health professionals (e.g., Baker & Lewis, 2013; Duggan, Heath, Lewis, & Baxter, 2012; Lewis & Baker, 2011; Lewis & Seko, 2016). To date, studies have investigated the motives as well as the potential risks and benefits of online NSSI activity. Findings from these efforts highlight a number of potentially important implications for researchers and clinicians. The current chapter offers both empirical and practical information concerning this burgeoning area.To this end, we first provide an overview of the forms of online activity related to NSSI. From here, we focus on the motivations for (or function of) online NSSI communication. Next, we discuss the potential benefits and risks associated with such communication. We then outline key implications for researchers in the field. Lastly, we offer research-​informed recommendations to guide practitioners working with individuals who engage in NSSI and who may also participate in related online behavior.

Types of Online Activity Related to NSSI Unsurprisingly, there are myriad online activities that individuals who self-​injure may use. Among the more salient online platforms used by youth and emerging adults to communicate about NSSI are social networks (e.g., Facebook, Twitter, Tumblr), which function to bring individuals and groups together to share messages and experiences via text, imagery, and video. Many social networks tend to involve individuals sharing their name, date of birth, and other identifying information (e.g., Facebook), whereas others tend to involve more covert profiles (e.g., Tumblr). The nature of content shared across social networks can

196  Stephen P. Lewis et al.

be public (i.e., accessible to anyone with internet access), private-​but-​public (i.e., accessible to members of the broader social network only), or private (i.e., accessible to an exclusive subset of members within a social network). Oftentimes, individuals create subgroups or connect with others through other means (e.g., via hashtags) focused on particular topics of interest. Beyond social networks, many also use online communities (e.g., message boards, discussion and chat fora) to discuss and share content about NSSI. These websites tend to have a more attenuated focus (e.g., exclusively about NSSI, mental health difficulties); thus, membership is usually smaller, comprising individuals who have common yet specific interests. Furthermore, these communities can be moderated (i.e., content posted by members is reviewed to ensure it is appropriate) or unmoderated (i.e., posts are not reviewed for content).As discussed later, unmoderated communities may carry risks for those who use them. While both social networks and online communities allow users to share photos and videos, some websites (e.g., Flickr, Pinterest, YouTube) exclusively cater to those who wish to share more visual content. Indeed, individuals who self-​injure commonly post and access NSSI imagery and videos when online (e.g., Baker & Lewis, 2013; Lewis & Baker, 2011; Sternudd, 2012). In many ways, these platforms also function in ways akin to social networks in that they allow users to comment on the material posted by other users and to connect with others through such means as hashtags (e.g., Instagram). Thus, it is important to bear in mind that many forms of online activity overlap. Although the platforms described above are largely interactional, other websites serve the primary purpose of providing NSSI information (e.g., facts, figures) and resources (e.g., coping strategies) without much interaction between site visitors.These websites may be developed by NSSI-​specific organizations or broader entities (e.g., universities, hospitals, non-​profits); however, it is also not uncommon for those with lived NSSI experience to create their own standalone website to provide NSSI information. Taken together, there is an abundance of online platforms on which individuals who self-​injure access material and communicate with others.The reasons for using these various platforms vary. Hence, we now turn our attention to the motives that individuals may have for different forms of online NSSI activity.

Motives for Online NSSI Activity Research suggests that individuals who engage in NSSI access online platforms and post NSSI-​related content for three primary reasons: (1) acceptance and validation (Brown et al., 2018; Johnson, Zastawny, & Kulpa, 2010; Jones et al., 2011; Lewis, Rosenrot, & Messner, 2012a; Murray & Fox, 2006; Rodham, Gavin, & Miles, 2007); (2) curiosity and understanding (Haberstroh & Moyer, 2012; Jacob, Evans, & Scourfield, 2017; Johnson, Zastawny, & Kulpa, 2010; Lewis & Michal, 2016); and (3) help-​seeking and help-​g iving (Frost & Casey, 2016; Haberstroh & Moyer, 2011; Lewis & Michal, 2016; Murray & Fox, 2006; Rodham, Gavin, Lewis, St. Denis, & Bandalli, 2013; Sternudd, 2012). These reasons notwithstanding, we

Understanding Online Self-Injury Activity  197

acknowledge that not all individuals purposefully seek out NSSI material online. There are apt to be some individuals who discover NSSI content inadvertently (e.g., when browsing on a more general social media platform; Jacob et al., 2017; Lewis & Michal, 2016). However, these instances appear to be less frequent (Jacob et al., 2017) and motivations for these individuals’ continued engagement in online NSSI activity likely mirrors what has been reported for those who actively seek out such material. Acceptance and Validation Individuals who engage in NSSI often experience negative reactions and stigma from friends, family, and even health care professionals (Rowe et al., 2014; Saunders, Hawton, Fortune, & Farrell, 2012; Whitlock, Powers, & Eckenrode, 2006). Therefore, the internet may hold appeal as it may appear to provide a safe space to connect with like-​minded others (Murray & Fox, 2006), namely those who also engage in NSSI. For instance, in a study examining questions pertaining to NSSI on Yahoo! Answers, many individuals posted questions in which they shared their NSSI experience and sought acceptance or validation from others (Lewis, Rosenrot, & Messner, 2012a). In line with this, Brown and colleagues (2018) argued that individuals may post NSSI photos to the popular photo-​sharing site, Instagram, because they receive social validation (i.e., via likes and comments). Overall, it seems that sharing their NSSI experiences with others who also self-​injure may yield to feeling more accepted, validated, and less judged (Jones et al., 2011; Lewis & Michal, 2016). Related to this, the role of anonymity that the internet affords is also of note (Jones et al., 2011; Murray & Fox, 2006; Lewis, Heath, Michal, & Duggan, 2012b; Lewis & Michal, 2016; Sternudd, 2012) as it has been reported that it may be easier to talk to a stranger about NSSI than family or friends (Jones et al., 2011). Curiosity and Understanding Individuals who engage in NSSI also report using the internet to learn about NSSI (Haberstroh & Moyer, 2012; Jacob, Evans, & Scourfield, 2017; Johnson et al., 2010; Lewis & Michal, 2016). For example, a thematic analysis conducted by Lewis and Michal (2016) found that individuals with an NSSI history began their online NSSI activity to enhance their NSSI knowledge and understand their experience. Similarly, another study found that most individuals turned to the internet to make sense of their behavior before using online communities as a means of connection with others (Jacob et al., 2017). Help-​S eeking and Help-​G iving Studies frequently cite help-​seeking and help-​giving as motives for online activity (Frost & Casey, 2016; Haberstroh & Moyer, 2012; Johnson et al., 2010; Lewis & Michal, 2016; Murray & Fox, 2006; Rodham et al., 2013; Sternudd, 2012). While professional help-​seeking is not common among individuals who engage in NSSI

198  Stephen P. Lewis et al.

(e.g., Lewis & Michal, 2016; Whitlock, Powers, & Eckenrode, 2006), Frost and Casey (2016) found that one-​third of their sample had turned online to seek help for NSSI. In some cases, individuals who self-​injure may turn to the internet to find adjunctive support for professional services, after experiencing disillusion with the medical establishment (Haberstroh & Moyer, 2012). An important aspect of the help sought online pertains to obtainment of social support and connection (Lewis & Michal, 2016;Whitlock et al., 2006). Indeed, many who self-​injure hold the view that those who do not engage in NSSI, even if they are trained in the mental health profession, cannot understand the experience of someone who does. Hence, help-​seeking related to online NSSI activity is not circumscribed to professional help-​seeking. In addition to getting help, individuals who engage in NSSI report that help-​giving motivates online communication. For example, researchers have found that individuals who self-​injure want to show others “they are not alone” (Lewis & Michal, 2016) and dissuade others from NSSI by showing how bad it can get (Rodham et al., 2013; Sternudd, 2012). Other Motives Individuals who engage in NSSI report a number of other reasons for posting NSSI content (e.g., imagery) online.These include but are not limited to: ease of communication (e.g., being able to contact someone from the comfort of one’s own home and at any time of day), freedom of expression, and dispelling myths associated with NSSI (e.g., that individuals who engage in NSSI have borderline personality disorder or self-​injure for attention) (Murray & Fox, 2006; Rodham et al., 2013; Sternudd, 2012). Some individuals use online platforms as a confessional to document their journey with NSSI and/​or recovery (Rodham et al., 2013; Sternudd, 2012). Others report that posting online alleviates the desire to self-​harm (Murray & Fox, 2006).

Potential Impact of Online NSSI Activity Perceived Benefits In the past two years, three systematic reviews (Dyson et al., 2016; Lewis & Seko, 2016; Marchant et al., 2017) have been published examining possible outcomes of internet use among individuals who engage in NSSI. Collectively, these efforts have highlighted four perceived benefits of online NSSI activity:  (1) mitigation of social isolation; (2) disclosure; (3) improvements in NSSI; (4) recovery encouragement and resource provision. Mitigation of Social Isolation By and large, the most commonly cited benefit of internet use for individuals who engage in NSSI is the mitigation of social isolation (Lewis, Heath, Michal, & Duggan, 2012b; Lewis & Seko, 2016). As highlighted above, individuals who

Understanding Online Self-Injury Activity  199

engage in NSSI commonly experience negative reactions and stigma from others that can serve as barriers to talking about NSSI (Rowe et  al., 2014). Online communities arguably provide a safe space for individuals to open up about their struggles and to connect with like-​minded peers (Adler & Adler, 2008; Haberstroh & Moyer, 2012).These connections appear to provide support (Baker & Lewis, 2013; Haberstroh & Moyer, 2012; Lewis et  al., 2012b) by allowing individuals to share and subsequently have their needs for acceptance, validation, and emotional support met (Lewis & Seko, 2016) through empathetic understanding (Baker & Fortune, 2008). Many individuals also report that connecting with peers through online platforms ultimately leads to reduced isolation (Haberstroh & Moyer, 2012; Johnson et al., 2010; Murray & Fox, 2006) and a sense of belonging within a community (Adler & Adler, 2008; Baker & Fortune, 2008; Johnson et  al., 2010; Haberstroh & Moyer, 2012; Niwa & Mandrusiak, 2012). In addition, both the provision and reception of supportive feedback have been identified as helpful by individuals accessing online NSSI platforms (Haberstroh & Moyer, 2012). Thus, within the context of mitigated social isolation, individuals who engage in NSSI may benefit specifically from supportive understanding (finding support from similar others), relational connections (forming bonds with others), and supportive feedback (providing and receiving feedback) (Haberstroh & Moyer, 2012). Disclosure The internet may be a low-​risk medium for disclosing difficult emotions and experiences, with little expectation of rejection (Lewis & Seko, 2016). Indeed, individuals who engage in NSSI often report feeling able to express thoughts and emotions online that they cannot in their offline lives (Rodham, Gavin, & Miles, 2007); this is likely due to fear of stigma (as noted above) or negative reactions from others (Rowe et  al., 2014; Saunders, Hawton, Fortune, & Farrell, 2012). In an experimental study, Owens and colleagues (2012) noted that participants were keen to share their experiences living with NSSI via online platforms. Similarly, Lewis and colleagues (2012c) found that the most frequent comments in response to NSSI YouTube videos were self-​disclosure comments (e.g., revealing one’s personal experience with NSSI). Moreover, freedom of emotional disclosure –​the ability to express emotions freely and without fear of judgment –​is intimately tied to expressing normally concealed parts of the self (Lewis & Seko, 2016). Individuals may, therefore, be more open to revealing their “true self ” online (Adler & Adler, 2008), allowing them to fully embrace and share their identity. Improvements in NSSI Some studies have found that online activity is associated with reductions in NSSI (Johnson et al., 2010; Murray & Fox, 2006) and improved coping (Baker

200  Stephen P. Lewis et al.

& Fortune, 2008). In one study, over 55% of participants reported a decrease in NSSI after joining an online message forum (Baker & Fortune, 2008). Here, it may be that the internet serves a similar purpose to NSSI. In particular, NSSI often functions to provide relief from and express difficult feelings (Haberstroh & Moyer, 2012). As the internet can provide a safe place for emotional expression, online NSSI activity, may, for some, displace the need for NSSI (Baker & Fortune, 2008). Alternatively, it may be that online activity serves as a distraction until NSSI urges subside. Other researchers have suggested that viewing NSSI images (e.g., photos) while online may curb NSSI urges (Baker & Lewis, 2013; Rodham et al., 2013; Sternudd, 2012), possibly by providing a sense of calmness and comfort (Sternudd, 2012). In addition to this, it may be that, while online, individuals gain access to coping strategies (e.g., emotion regulation techniques) to use when experiencing urges to self-​injure. Adding support for this latter possibility is research indicating that coping resources are widespread online (Lewis, Mahdy, Michal, & Arbuthnott, 2014) and findings indicating that individuals may actively look for NSSI coping resources when online (Lewis & Michal, 2016). Recovery Encouragement and Resource Provision A final perceived benefit of internet use among individuals who self-​injure is recovery encouragement (Lewis & Seko, 2016), outreach, and engagement (Marchant et  al., 2017). As mentioned above, online activity may facilitate reductions in NSSI. Moreover, some sites promote help-​seeking outside of the online environment (e.g., Niwa & Mandrusiak, 2012). For instance, in one study examining NSSI message boards, almost half of the posts related to help-​ seeking for NSSI encouraged formal treatment (Whitlock et al., 2006). In line with the provision of coping strategies, the internet may serve as a means to disseminate recovery-​focused materials (Duggan et  al., 2012; Marchant et  al., 2017) and stories (Lewis & Michal, 2016). Evidence suggests that there is a high volume of searches conducted via major search engines (e.g., Google) using NSSI-​related keywords, thereby pointing to the potential need to find NSSI-​ related materials (Duggan et al., 2012; Lewis et al., 2014; Swannell et al., 2010). However, researchers have found that even with commonly sought out terms, the websites found in the corresponding search results may be of questionable quality. For example, Lewis and colleagues (2014) found that of the 340 sites analyzed, there was on average one NSSI myth (e.g., that individuals who self-​injure have borderline personality disorder) per site. Relatedly, the overall quality of health information on these websites was low. Thus, while resource provision represents a possible benefit of online communication for individuals who engage in NSSI, efforts may be needed to ensure that users have easy access to reputable and high-​quality material informed by research. For this reason, we provide Table 12.1 which has recommended resources that can be provided to clients and other key stakeholders (e.g., caregivers, partners).

Understanding Online Self-Injury Activity  201 Table 12.1 Recommended Resources for Those Engaging in NSSI and Other Stakeholders Organization name

URL

Content provided

Self-​Injury Outreach and Support (SiOS)

www.sioutreach.org

Cornell Research Program on Self-​injury and Recovery

www.selfinjury.bctr. cornell.edu

Self Abuse Finally Ends (S.A.F.E.)

www.selfinjury.com

Shedding Light on Self-​injury

www.self-​injury. org.au

Offers empirically informed resources about self-​injury to individuals who self-​injure, including coping guides and recovery stories from those with lived experience. SiOS also offers guides for families; friends; romantic partners; and various health and mental professionals. Based at Cornell University, this website provides an array of information concerning self-​injury. This includes resources for those who self-​injure as well as information for those who can play supportive roles, such as families, schools, and professionals. Provides a treatment approach, network, and educational resources for individuals engaging in NSSI, caregivers, families, and educational and health professionals. This online resource has information for health professionals, as well as general information for anyone wanting more information about self-​injury.

Potential Risks Despite the possible benefits discussed above, several potential risks may also associate with online NSSI activity. Indeed, reviews of the literature in this area (Dyson et al., 2016; Lewis & Seko, 2016; Marchant et al., 2017) have identified the following major potential risks:  (1) reinforcement (e.g., Lewis & Baker, 2011; Lewis et  al., 2012b); (2)  triggering urges (e.g., Baker & Lewis, 2013; Sternudd, 2012); and (3)  stigmatization (e.g., Lewis et  al., 2014; Zdanow & Wright, 2012). NSSI Reinforcement The most commonly cited risk linked to online NSSI activity pertains to the notion that certain kinds of online activity may work to reinforce NSSI engagement among those who self-​injure (i.e., increasing the likelihood that the individual will continue to self-​injure). This may occur in several ways. For instance,

202  Stephen P. Lewis et al.

across numerous online platforms, people’s experiences with NSSI are often shared in the context of hopeless messages where the prospect of recovery is positioned as difficult or not possible (Lewis & Seko, 2016). Indeed, NSSI depictions across numerous websites (e.g., Tumblr, YouTube) involve people sharing their NSSI experiences alongside melancholic emotional themes (e.g., music) and an emphasis on their despair (Lewis & Baker, 2011; Lewis et  al., 2011; Seko & Lewis, 2018). Furthermore, researchers have found that responses to these depictions (e.g., via comments to a post) similarly carry hopeless tones, with little emphasis on recovery (e.g., Lewis, Heath, Sornberger, & Arbuthnott, 2012c). It has therefore been suggested that repeated access to these kinds of messages and themes may perpetuate a narrative that recovery from NSSI is not viable, which may, in turn, impede recovery incentive or motivation. NSSI may also be reinforced by individuals sharing ways to conceal NSSI or even self-​injure (e.g., use of new methods or locations on the body to injure), by promoting NSSI as an acceptable behavior (e.g., justification of NSSI as a means to respond to and regulate distress), or by sharing first-​aid tips for use after an NSSI episode (e.g., how to care for a wound without medical assistance). For example, in a study examining the nature of posts on discussion boards, it was found that individuals often shared techniques to injure themselves in ways that would reduce the likelihood of others (e.g., caregivers) discovering any resulting injury (Whitlock et al., 2006). In another study, it was reported that over 50% of personal NSSI websites involved discussions of ways to self-​injure and conceal NSSI from others (Lewis & Baker, 2011), with another 29% offering first-​aid strategies. First-​aid strategies have also been studied on YouTube; here, these tips are provided, often with the implication that NSSI does not warrant professional intervention and that NSSI is an acceptable means of coping (Lewis & Knoll, 2015). Much like hopeless messages, it has been suggested that repeated access to the above messages may work to reinforce NSSI (see Lewis & Seko, 2016). Triggering Another domain of concern is that some individuals who self-​injure may access NSSI-​themed material that provokes (i.e., triggers) urges to self-​injure (e.g., Lewis & Baker, 2011; Sternudd, 2012). Indeed, several studies provide support for the potential for certain kinds of NSSI content to increase distress and even urges to self-​injure (Lewis & Baker, 2011; Sternudd, 2012). This may have particular relevance in the context of more graphically portrayed content, such as detailed descriptions of NSSI episodes or photos of NSSI injuries (e.g., Baker & Lewis, 2013; Lewis & Baker, 2011; Lewis et  al., 2011). Although trigger warnings are commonly posted alongside NSSI content that is ostensibly more graphic, there is evidence to suggest that these may be ineffective (Baker & Lewis, 2013). Moreover, what constitutes triggering material may vary person to person. For example, as discussed above, some individuals may find that accessing material that would seem graphic (e.g., NSSI images) will serve to curb their

Understanding Online Self-Injury Activity  203

NSSI urges versus incite them. Given these discrepant reports, further research is warranted in this area to not just understand what types of material are most often triggering and which individuals may be most vulnerable to this content, but to elucidate some of the mechanisms involved in this process. Stigmatization Although many online communities provide an outlet for those who self-​injure to discuss and share their experiences, find resources, as well as obtain and provide support, there are also reports that engaging in online NSSI activity may lead to stigmatization (see Lewis & Seko, 2016). This may occur through the nature of comments that those who self-​injure may receive, especially when comments are unmoderated. Indeed, Niwa and Mandrusiak (2012) found that over 21% of NSSI-​related Facebook groups included comments that ridiculed or criticized NSSI (e.g., “Happy slashing peeps and remember to switch off your phones”; p. 12). Stigmatizing and hostile comments has also been observed in response to YouTube videos regarding NSSI (Lewis et  al., 2012c) and Yahoo! Answers (Lewis et al., 2012a). In many ways, these findings underscore the need for NSSI communities to have some degree of moderation to safeguard against trolling and cyber-​bullying, which may exacerbate feelings of isolation and being misunderstood.

Avenues for Future Research As reviewed above, there is evidence that online NSSI activity may be associated with benefits and risks (for reviews see Dyson et al., 2016; Lewis & Seko, 2016; Marchant et al., 2017), reflecting a double-​edged effect of such online behavior (Lewis & Seko, 2016). However, research in this area is still in its infancy, which is, in part, due to the rapid advancement of technology and the continued emergence of new arenas in which individuals communicate about NSSI. As a result, there are many unanswered questions regarding NSSI and online communication. Direct Association between NSSI and Online Communication To date, only one study has looked at the association between online NSSI activity and behavior (Mitchell, Wells, Priebe, & Ybarra, 2014), suggesting the need for replication studies. Here, researchers found that individuals who accessed suicide or self-​harm websites reported greater thoughts of self-​harm than those who did not access these websites (Mitchell et al., 2014). However, Mitchell and colleagues (2014) examined only one aspect of self-​harm (i.e., thoughts of self-​harm). It would be advantageous for investigators to consider multiple NSSI-​related variables (e.g., attitudes, methods, frequency). Doing so may provide a more comprehensive understanding of the association between

204  Stephen P. Lewis et al.

online NSSI activity and behavior. Future research should also differentiate between NSSI, general self-​harm behaviors, and suicide in effort to determine the precise relationship between online activity and NSSI (Lewis & Seko, 2016). Moreover, research is needed to delineate the mechanisms involved in both the risks and benefits associated with online NSSI activity. In particular, Lewis and Seko (2016) suggest the need for experimental research in which individuals are randomly assigned to online conditions with varying levels of NSSI exposure to examine the potential impact on factors such as NSSI thoughts, attitudes, or urges; although potentially promising, this line of inquiry may prove difficult given its inherent ethical considerations. Who is Affected by Online NSSI Activity? There is a dearth of research examining which individuals (of those who engage in NSSI) may be more impacted by online NSSI activity with respect to its potential benefits and risks. One way to address this gap in the field would be to conduct studies using different subgroups (e.g., those who experience reductions in NSSI after engaging in online NSSI activity, those who experience an increase in NSSI after engaging in online NSSI activity) in the study of online NSSI activity. These lines of inquiry would also require longitudinal approaches to determine the temporal impact (if any) of different forms of online activity on NSSI-​related features (e.g., urges, frequency of behavior). In addition to this, it remains unclear whether vulnerable individuals who have never self-​injured are at risk for NSSI as a result of accessing online NSSI material. Most research in this area involves those who have already self-​injured, despite some reason to believe that certain forms of material may contribute to NSSI initiation (e.g., implying that NSSI is a helpful method to cope; Baker & Lewis, 2013; Lewis & Knoll, 2015); thus, determining whether a social contagion effect occurs in the context of online NSSI activity warrants attention. Understanding the Role of the Internet in Treatment for NSSI Consistent with guidelines for NSSI assessment (see below) that clinicians must be aware of their clients’ online activity, it is important to delineate the effect of online communication over the course of treatment. This includes –​but is not limited to –​understanding how the client’s online activity affects treatment outcome (i.e., do individuals with higher online engagement during treatment have better/​worse treatment outcomes?), how discussions between the clinician and client regarding functional logs affect online activity and NSSI enactment, and how the clinician’s understanding of online NSSI activity affects therapeutic alliance. We highlight the particular need for longitudinal research in this domain. Namely, where a client’s internet use is likely to change over the course of treatment and with the use of functional logs, understanding the role of online activity in treatment outcome will depend largely on being able to map

Understanding Online Self-Injury Activity  205

internet use and NSSI activity over a prolonged period of time. In this regard, the use of ecological momentary assessment may have utility. Notwithstanding the risks discussed in the previous section, it is important to acknowledge the importance of the internet and e-​communication for individuals who engage in NSSI. By virtue of their sustained and vibrant engagement with these platforms, the internet may be a useful adjunct to current therapeutic approaches. Research is necessary to elucidate which aspects of online communication may be adaptable for clinical practice. For example, electronic functional logs may be completed using portable apps.While the use of such adjuncts is enticing, we are still quite some time away from understanding the nature of internet use in the treatment of NSSI. Finally, it is widely known that rates of NSSI help-​seeking are low (e.g., Lewis & Michal, 2016; Whitlock et al., 2006). Part of this may stem from the fact that many individuals who engage in NSSI prefer obtaining support for and resources about NSSI via non-​traditional means such as the internet. It is therefore incumbent upon researchers and others in the field to think broadly about the ways that the internet can be harnessed to not only reach but also help those who may not use typical means of help-​seeking.This seems especially important considering the mismatch between the number of individuals who could benefit from such efforts and the smaller number of professional services available.

Recommendations for Clinicians When embarking on clinical work with clients who engage in NSSI, attention to the possible role that online NSSI activity may have is essential. Of note is ascertainment of the extent to which such behavior impacts the progression of treatment. With this in mind, we now turn to research-​informed considerations for assessment and treatment in this burgeoning but important area in the NSSI field. Familiarization with Online Nomenclature As highlighted earlier, the internet holds appeal and salience among many who self-​injure (for review, see Lewis & Seko, 2016), and this may be especially the case for adolescents and emerging adults, who engage in more online communication than other age groups (Heath, Baxter,Toste, & McLouth, 2010; Lewis & Seko, 2016; Mitchell & Ybarra, 2007). The same level of familiarity with online activity may not apply to some clinicians, who tend to not use the internet to the same degree or in the same ways (Lewis et al., 2012b; Whitlock et al., 2007). Hence, a first step toward working with clients who engage in both NSSI and related online activity is to become acquainted with the nature of online activities their clients might enact. Becoming familiar with these terms can facilitate assessment and intervention.

206  Stephen P. Lewis et al.

Assessing Online NSSI Activity Unfortunately, despite its double-​edged nature, most reports concerning online NSSI activity place a greater spotlight on its potential risks, with less emphasis on its potential benefits (Lewis et al., 2012b, 2014; Sornberger, Joly, Heath, & Lewis, 2012).Thus, awareness of the totality of risks and benefits associated with such online behavior is critical. Indeed, it cannot be assumed that clients who engage in NSSI and who use the internet are necessarily engaging in harmful online activity. Knowledge of both the potential risks and benefits of online NSSI communication can aid in building rapport with individuals by conveying a sense of understanding that clients may be differentially affected by what they do online and that any online NSSI activity likely serves a purpose for clients. Akin to recommendations for assessing NSSI (Klonsky & Lewis, 2014; Klonsky, Muehlenkamp, Lewis, & Walsh, 2011), and informed by published guidelines for addressing online NSSI activity in clinical contexts (Lewis et al., 2012b; Lewis & Arbuthnott, 2014), the use of a functional assessment may have merit when understanding a client’s online NSSI activity. A central goal of this approach, especially early in treatment, is to shed light on the range of internet behaviors that clients are enacting. In the initial stages of assessment, clinicians can introduce clients to the role of a functional log as a tool central to tracking their online activity outside of sessions. By virtue of using the functional logs, clinicians will be in a better position to obtain important information concerning a client’s online behavior; and completing functional logs helps to draw clients’ awareness to the nature of what they do online. When introduced to the functional log, clients should be asked to complete the log between the session in which it is first introduced and the subsequent session. Checking-​in about the use of the log in the follow-​up session affords the opportunity to address questions or concerns the client might have and to troubleshoot issues (e.g., forgetting to complete the log, low buy-​in) in a collaborative manner. From here, the functional log can be used to collect ongoing information between sessions. When using the functional log, focus should be on the temporal nature of online NSSI activity. This should entail obtainment of information about: (1) antecedents to online NSSI activity, including any events/​interactions, thoughts, and feelings leading up to the online activity; (2) what transpires when the client is online, including the nature of what they are doing as well as the thoughts and feelings their online activity evokes; and (3) the consequences of the online activity, including any events/​interactions, thoughts, and feelings following the online activity. Regular use of a functional log for these purposes allows for ongoing monitoring of what may be helping or hindering treatment progress. Moreover, information gleaned from the log can be discussed as part of therapy sessions, thereby helping clinicians to understand the potential effect clients’ online activity may have. This is especially important as the types and impact of online activity may change over the course of treatment.

Understanding Online Self-Injury Activity  207

As clients complete the functional log and more is learnt about the nature of their online NSSI activities, a more comprehensive line of inquiry can enhance the assessment. To guide this process, Table  12.2 offers pragmatic and potentially helpful questions for practitioner use. Employing these types of query can help establish the extent to which client’s online activity is deleterious (e.g., Table 12.2 Questions to Guide Practitioners Activity type and frequency When you are online, do you look for or access material related to self-​injury? What do you access? How often do you do this (e.g., daily, weekly, monthly)? Are there particular times of day you might do this more often? If the website provides NSSI information What kind(s) of resources or information have you accessed about self-​injury when online? Do you know who makes the website (e.g., a hospital, university, someone who self-​injures)? Is the website moderated? By whom (e.g., mental health professional, peers)? What do you do when you visit these websites (e.g., reading/​browsing, posting material)? Are you a member of an online group related to self-​injury (e.g., message board, social network group)? Is the group public or private? Is the group moderated? By whom? What is the core theme of the group (e.g., pro-​NSSI, support)? Do you have online friendships with others you’ve met regarding self-​injury? What is the nature of the relationship(s)? What do you do when you visit these websites (e.g., reading/​browsing, posting material)? Media Sharing What type of content do you view (e.g., photos, videos)? Do you create and share content (e.g., photos, videos)? What kind of material? What kind of message or theme do your posts have? Can you help me to understand why you post this material? Are there visual presentations of self-​injury? Pictures, videos? Are there trigger warnings? Do you use them? What are the themes of the visual presentations (e.g., pro-​NSSI)? Is the content triggering? What makes it triggering? To what degree and intensity? Functional Assessment When and why did you first go online concerning self-​injury? Has engaging in online activity related to self-​injury changed your self-​injury? How so (e.g., frequency)? Do you self-​injure before or after engaging in online activity related to self-​injury? Can you help me understand that (e.g., how long before/​after, where does this happen)? Note: Adapted from Lewis et al., 2012b.

208  Stephen P. Lewis et al.

accessing triggering content, reading bleak message about recovery), supportive (e.g., accessing messages encouraging recovery or coping strategies), or perhaps even both. Notwithstanding the import of elucidating the kinds of online activities used by clients (e.g., watching a YouTube video versus posting NSSI images on Instagram), focus should broaden to other features of online behavior. Indeed, it is conceivable that some clients may inaccurately report what they do when they go online (e.g., minimizing how often they go online) or be unaware that their online activity is having an adverse effect on them (e.g., reinforcing their NSSI engagement). Hence, determining the frequency and duration of the client’s online activity is warranted.This should also involve understanding when a client’s online activity transpires (e.g., whether it occurs at particular times of the day or night). Integrating this within the context of a functional assessment (i.e., identifying antecedents and consequences of online NSSI activity) will put clinicians in a position to better comprehend the ways that online activity may impact on a client’s NSSI and well-​being (Lewis et al., 2012b). Approaches for Intervention In keeping with the above, establishing precursors to online NSSI activity alongside potential reinforcing factors works to inform intervention plans. While it may seem optimal for certain online activities to be immediately curtailed, many clients will not be ready for this; moreover, a good number of individuals will view online NSSI activity as a fundamental source of validation, acceptance, and support (Lewis et al., 2012b; Lewis & Seko, 2016). Accordingly, clinicians ought to be cautious and avoid making assumptions or conclusions regarding what types of online behavior are potentially harmful. If clients are engaging in online activities that pose clear risks, interventions focusing on altering this kind of online behavior will be necessary; strategies to facilitate this are presented next. Fostering change in the context of curbing harmful online NSSI activities can represent an arduous clinical task. Indeed, some clients may not view their online behavior as problematic. Further, it is likely that clients’ online activity serves a function (e.g., providing support and validation); if so, there may be reluctance to discontinue these activities altogether. Demanding or even requesting that clients desist engagement in online NSSI activity is therefore not advised for a couple of reasons. First, it is critical that clinicians focus on identifying the impact of online NSSI activity on the clients; if clients are asked to not engage in online activity this cannot be accomplished. Second, asking clients to refrain from online NSSI activity may engender secrecy. Understandably, if a client’s online activity has detrimental effects (e.g., it triggers or exacerbates NSSI), secrecy about these behaviors would be ineffectual –​both therapeutically and in the client’s recovery. Drawing on published guidelines for addressing NSSI (Klonsky, Muehlenkamp, Lewis, & Walsh, 2011; Washburn et al., 2012) and online NSSI

Understanding Online Self-Injury Activity  209

activity in clinical settings (Lewis et al., 2012b), we advocate working with clients to determine their readiness to change their online activity. To this end, utilization of the stages of change framework (Prochaska & Velicer, 1997) may have merit. This model has been implicated for its utility in the conceptualization of NSSI recovery and clients’ readiness to work toward stopping NSSI (Grunberg & Lewis, 2015; Kress & Hoffman, 2008). It has also been recommended when addressing online NSSI activities (Lewis et al., 2012b). Consistent with this approach, motivational interviewing (MI) could be relevant and serve as a means to successfully address reluctance or ambivalence toward the prospect of stopping online NSSI activity. This, in turn, can work to promote agency and thus incentivize clients to make changes to their online behavior. Indeed, MI has been shown to have promise in eliciting desire to change among individuals who self-​injure (Kress & Hoffman, 2008) and individuals with internet addiction (Griffiths & Meredith, 2009). Thus, as noted by others, there is reason to believe that MI holds some promise for use with clients who engage in problematic online NSSI activity (see Lewis et al., 2012b). As clients become more engaged in the therapeutic process and more open to considering the use of activities in place of online behavior that is otherwise harmful, clinicians can draw from a repertoire of strategies to help clients replace problematic online behavior. For example, working with clients to collaboratively develop a list of alternative offline activities (e.g., exercise, communicating with friends or family, journaling, mindfulness) may be fruitful. This may have particular relevance if it is deemed that online activity occurs prior to or in response to NSSI thoughts or urges. At the same time, as discussed earlier, dissuading clients from all online activity is not recommended, nor is it likely to be viable. Because of this, consideration of those online activities which pose little to no risk may be warranted. Specifically, this involves introducing and directing individuals to reputable, recovery-​oriented online platforms. In tandem with this, utilization of a functional log to assess the effect of such activities is suggested; doing so can increase client insight into the impact of their online activities while providing a new set of healthier online behaviors. With research indicating that many online resources for NSSI are not always helpful, we have created a list of reputable online resources that can be introduced and recommended for use with clients (please see Table 12.1). In as much as it is important to check in with clients about online activity that may be risky, it is equally important to check in about their use of online resources that could be helpful.This is a key part of determining the extent to which their online activities (and changes therein) correspond to changes in client well-​being.

Case Vignette Sophie recently turned 16 years old and has struggled with self-​injury since she was 14. Since this time, she has cut herself on a sporadic basis, usually on her upper thigh. Recently, her self-​injury has become much more frequent and she

210  Stephen P. Lewis et al.

has begun cutting her arms. Sophie says that she can be “really hard on myself ” and reports having very low self-​esteem. She attributes this to being bullied at school. She says that self-​injury let’s her “see how ugly I am” and helps her feel “a bit better” when she gets “really upset.” Although Sophie had kept her self-​ injury hidden for some time, her parents recently noticed fresh cuts on her lower arm, which resulted in bringing Sophie to see a therapist. Over the course of their first few sessions, Sophie’s therapist conducted a thorough assessment to understand Sophie’s self-​injury and the various factors that contributed to its initiation, maintenance, and recent exacerbation. During one of their meetings, Sophie’s therapist asked if anyone knew about Sophie’s self-​injury. Sophie replied by saying, “no … not really.” Curious about this, Sophie’s therapist normalized that “self-​injury can be really hard to talk about with others, including me. Sometimes when people feel they can’t tell others such as family or friends they talk about it online. I’m wondering if this is something you have done?” Sophie nodded that this was the case for her. This led to conversation about the kinds of online activity Sophie used in relation to her self-​injury. Accordingly, Sophie’s therapist introduced the use of a functional log. To facilitate introduction of the functional log, Sophie’s therapist focused on a recent incident in which Sophie went online. The event occurred two nights prior, after her parents had gone to bed. Sophie expressed feeling “upset” and “lonely” at the time; she said that she could not sleep because of this. Hence, she decided to go online to read about others’ experiences as she said this helps her. She indicated that reading about others’ stories help her feel less alone and “less like a freak.” Sophie also commented that some people have posted coping strategies which she finds helpful. On this particular night, Sophie read a new post from a member of the message board. The post had a direct link to a YouTube video. Sophie clicked on the link and began to watch the video, which had very graphic photographs of self-​injury. Sophie found this very “triggering … like, it made me want to do it.” Although she did not act on her urge, she noted that the experience was very upsetting. Sophie’s therapist validated Sophie’s experience and commended her ability to resist the urge to cut in a moment that was likely very difficult for her. By focusing on this recent and specific event, Sophie and her therapist collaboratively completed the log. During this exercise, Sophie made a few initial associations between some of the thoughts (“no one likes me”) and feelings (loneliness, sadness) that led to her going online. She was also able to draw links between the content she accessed (i.e., the video) and the way this made her feel (e.g., distressed, triggered). Although Sophie recognized that the video’s graphic content led to an urge to self-​injure, she was clear that this would not dissuade her from visiting the Facebook group or watching self-​injury videos on the internet in the future. She expressed that the group “is usually pretty helpful” and that the video “was just one stupid post.” Her therapist validated Sophie’s experience. Before wrapping up their session, Sophie and her therapist agreed that Sophie would complete

Understanding Online Self-Injury Activity  211

the log a few times over the next week. As part of this conversation, both Sophie and her therapist identified a few obstacles (e.g., forgetting) that might impede this; accordingly, they implemented a few strategies to help with the completion of the log (e.g., adding reminders in her phone) between sessions. Over the next several sessions, Sophie continued to complete the functional log, which was collaboratively reviewed by Sophie and her therapist. This allowed for Sophie to further understand that while she obtained the support through the Facebook group and other online platforms she accessed, she also encountered some material that was upsetting and triggering. Using evidence from the log, Sophie’s therapist embarked on a conversation with Sophie regarding the advantages and disadvantages associated with some forms of her online activity. Recognizing that Sophie was unwilling to stop going online altogether, her therapist used motivational interviewing techniques, which allowed Sophie to generate her own reasons for and against different types of online behavior. As their discussions progressed, Sophie began to recognize that she had more reasons to refrain from watching videos about self-​injury (one particular form of online NSSI activity), as they tended to trigger her. This segued to Sophie’s therapist to discuss healthy online activities with Sophie. When asked what such online activity might look like, Sophie was unable to generate suggestions beyond the Facebook group she had previously visited. To help with this, Sophie’s therapist shared a list of recommended websites (Table 12.1) that Sophie could use when she felt upset or had urges to hurt herself. In keeping with their other work to help Sophie reduce and eventually stop her self-​injury, they also collaboratively developed a list of offline strategies that Sophie could also use. As therapy progressed, Sophie stopped watching self-​injury videos online and eventually started to access the Facebook group less often, commenting that “I dunno … I just don’t feel like I need to go there as much.” Alongside their work addressing online self-​injury activity, Sophie and her therapist worked on an array of strategies rooted in dialectical and cognitive behavior therapies for self-​injury. This included fostering distress tolerance and work on Sophie’s self-​esteem and self-​criticism. As therapy progressed, Sophie’s self-​injury became much less frequent and she began to talk about her feelings more with her parents, which she found “surprisingly helpful!”

References Adler, P. A., & Adler, P. (2008). The cyber worlds of self-​injurers: Deviant communities, relationships, and selves. Symbolic Interaction, 31, 33–​56. Baker, D., & Fortune, S. (2008). Understanding self-​harm and suicide websites: A qualitative interview study of young adult website users. Crisis, 29, 118–​122. doi:10.1027/​ 0227-​5910.29.3.118. Baker, T. G., & Lewis, S. P. (2013). Responses to online photographs of nonsuicidal self-​ injury:  A thematic analysis. Archives of Suicide Research, 17, 223–​235. doi:10.1080/​ 13811118.2013.805642

212  Stephen P. Lewis et al. Brown, R. C., Fischer, T., Goldwich, A. J., Keller, F., Young, R., & Plener, P. L. (2018). #Cutting:  Non-​suicidal self-​injury (NSSI) on Instagram. Psychological Medicine, 48, 347–​346. Duggan, J.  M., Heath, N.  L., Lewis, S.  P., & Baxter, A.  L. (2012). An examination of the scope and nature of non-​suicidal self-​injury online activities:  Implications for school mental health professionals. School Mental Health, 4, 56–​ 67. doi:10.1007/​ s12310-​011-​9065-​6. Dyson, M. P., Hartling, L., Shulhan, J., Chisholm, A., Milne, A., Sundar, P., … Newton, A. S. (2016). A systematic review of social media use to discuss and view deliberate self-​ harm acts. PLoS ONE, 11, e0155813. doi:10.1371/​journal.pone.0155813. Frost, M., & Casey, L. (2016). Who seeks help online for self-​injury? Archives of Suicide Research, 20, 69–​79. doi:10.1080/​13811118.2015.1004470. Griffiths, M. D., & Meredith, A. (2009).Videogame addiction and its treatment. Journal of Contemporary Psychotherapy, 39, 247–​253. Grunberg, P. H., & Lewis, S. P. (2015). Self-​injury and readiness to recover: Preliminary examination of components of the stages of change model. Counselling Psychology Quarterly, 28, 361–​371. Haberstroh, S., & Moyer, M. (2012). Exploring an online self-​injury support group: Perspectives from group members. The Journal for Specialists in Group Work, 37, 113–​ 132. doi:10.1080/​01933922.2011.646088. Heath, N. L., Baxter, A. L., Toste, J. R., & McLouth, R. (2010). Adolescents’ willingness to access school-​based support for nonsuicidal self-​injury. Canadian Journal of School Psychology, 25, 260–​276. Jacob, N., Evans, R., & Scourfield, J. (2017).The influence of online images on self-​harm: A qualitative study of young people aged 16–​24. Journal of Adolescence, 60, 140–​147. Johnson, G. M., Zastawny, S., & Kulpa, A. (2010). E-​message boards for those who self-​ injure: Implications for E-​health. International Journal of Mental Health and Addiction, 8, 566–​569. doi:10.1007/​s11469-​009-​9237-​x. Jones, R., Sharkey, S., Ford, T., Emmens, T., Hewis, E., Smithson, J., … Owens, C. (2011). Online discussion forums for young people who self-​harm: User views. The Psychiatrist, 35, 364–​368. doi:10.1192/​pb.bp.110.033449. Klonsky, E. D. & Lewis, S. P. (2014) Assessment of non-​suicidal self-​injury. In M. K. Nock (Ed.). Oxford handbook of suicide and self-​injury. New York: Oxford University Press. Klonsky, E. D., Muehlenkamp, J. J., Lewis, S. P. & Walsh, B. (2011). Non-​suicidal self-​injury. Cambridge, MA: Hogrefe & Huber. Kress,V., & Hoffman, R. (2008). Non-​suicidal self-​injury and motivational interviewing: Enhancing readiness for change. Journal of Mental Health Counseling, 30, 311–​329. Lewis, S. P. & Arbuthnott, A. E.* (2014). Non-​suicidal self-​injury, eating disorders: The influence of the internet and social media. In L. Claes & J. Muehlenkamp (Eds.). Non-​ suicidal self-​injury in eating disorders. New York, NY: Springer. Lewis, S. P., & Baker, T. G. (2011). The possible risks of self-​injury web sites: A content analysis. Archives of Suicide Research, 15, 390–​396. doi:10.1080/​13811118.2011.616154 Lewis, S. P., Heath, N. L., Michal, N. J., & Duggan, J. M. (2012b). Non-​suicidal self-​injury, youth, and the internet:  What mental health professionals need to know. Child and Adolescent Psychiatry and Mental Health, 6, 13. Lewis, S.  P., Heath, N.  L., Sornberger, M.  J., & Arbuthnott, A.  E. (2012c). Helpful or harmful? An examination of viewers’ responses to nonsuicidal self-​injury videos on YouTube. The Journal of Adolescent Health, 51, 380–​385.

Understanding Online Self-Injury Activity  213 Lewis, S. P., Heath, N. L., St. Denis, J. M., & Noble, R. (2011). The scope of non-​suicidal self-​injury on YouTube. Pediatrics, 127, e552–​557. Lewis, S. P., & Knoll, A. (2015). Do it yourself: Examination of self-​injury first aid tips on Youtube. Cyberpsychology, Behavior, & Social Networking, 18, 301–​304. Lewis, S.  P., Mahdy, J.  C., Michal, N.  J., & Arbuthnott, A.  E. (2014). Googling self-​ injury:  The state of health information obtained through online searches for self-​ injury. JAMA Pediatrics, 168, 443–​449. doi:10.1001/​jamapediatrics.2014.187. Lewis, S. P., & Michal, N. J. (2016). Stop, start, and continue: Preliminary insight into the appeal of self-​injury e-​communication. The Journal of Health Psychology, 21, 250–​260. doi:10.1177/​1359105314257140. Lewis, S. P., Rosenrot, S. A., & Messner, M. A. (2012a). Seeking validation in unlikely places: The nature of online questions about non-​suicidal self-​injury. Archives of Suicide Research, 16, 263–​272. doi:10.1080/​13811118.2012.695274. Lewis, S.  P., & Seko, Y. (2016). A double-​edged sword:  A review of benefits and risks of online nonsuicidal self-​injury activities. Journal of Clinical Psychology, 72, 249–​262. doi:10.1002/​jclp.22242 Marchant, A., Hawton, K., Stewart, A., Montgomery, P., Singaravelu, V., Lloyd, K., … John,  A. (2017). A systematic review of the relationship between internet use, self-​ harm, and suicidal behavior in young people: The good, the bad, and the unknown. PLoS ONE, 12, e0181722. doi:10.1371/​journal.pone.0181722. Mitchell, K. J., Wells, M., Priebe, G., & Ybarra, M. L. (2014). Exposure to websites that encourage self-​harm and suicide: Prevalence rates and association with actual thoughts of self-​harm and thoughts of suicide in the United States. Journal of Adolescence, 37, 1335–​1344. doi:10.1016/​j.adolescence.2014.09.011. Mitchell, K. J., & Ybarra, M. L. (2007). Online behavior of youth who engage in self-​ harm provides clues for preventive intervention. Preventative Medicine, 45, 392–​396. Murray, C.  D., & Fox, J. (2006). Do internet self-​harm discussion groups alleviate or exacerbate self-​harming behavior? Australian e-​Journal for the Advancement of Mental Health, 5, 225–​233. doi:10.5172/​jamh.5.3.225 Niwa, K. D., & Mandrusiak, M. N. (2012). Self-​injury groups on Facebook. Canadian Journal of Counseling and Psychotherapy, 46, 1–​20. Owens, C., Sharkey, S., Smithson, J., Hewis, E., Emmens, T., Ford, T., & Jones, R. (2012). Building an online community to promote communication and collaborative learning between health professionals and young people who self-​harm: An exploratory study. Health Expectations, 18, 81–​94. doi:10.1111/​hex.12011. Perrin, A. (2015). Social media usage: 2005–​2015. Retrieved from: www.pewinternet.org/​ 2015/​10/​08/​social-​networking-​usage-​2005–​2015/​ Poushter, J. (2016). Smartphone ownership and internet usage continues to climb in emerging economies. Retrieved from: www.pewglobal.org/​2016/​02/​22/​smartphone-​ownership-​ and-​internet-​usage-​continues-​to-​climb-​in-​emerging-​economies/​ Prochaska, J. O., & Velicer, W. F. (1997). The transtheoretical model of health behavior change. American Journal of Health Promotion, 12, 38–​48. Rodham, K., Gavin, J., Lewis, S. P., St. Denis, J., & Bandalli, P. (2013). An investigation of the motivations driving the online representation of self-​injury: A thematic analysis. Archives of Suicide Research, 17, 173–​183. doi:10.1080/​13811118.2013.776459. Rodham, K., Gavin, J., & Miles, M. (2007). I hear, I listen, I care: A qualitative investigation into the function of a self-​harm message board. Suicide and Life-​Threatening Behavior, 37, 422–​430.

214  Stephen P. Lewis et al. Rowe, S. L., French, R. S., Henderson, C., Ougrin, D., Slade, M., & Morgan, P. (2014). Help-​seeking behavior and adolescent self-​harm: A systematic review. Australian and New Zealand Journal of Psychiatry, 48, 1083–​1095. Saunders, K. E. A., Hawton, K., Fortune, S., & Farrell, S. (2012). Attitudes and knowledge of clinical staff regarding people who self-​harm: A systematic review. Journal of Affective Disorders, 139, 205–​216. doi:10.1016/​j.jad.2011.08.024. Seko, Y., & Lewis, S. (2018). The self-​harmed, visualized, and reblogged: Remaking of self-​injury narratives on Tumblr. New Media & Society, 20, 180–​192. Sornberger, M., Joly, M., Heath, N.  L., & Lewis, S.  P. (2012, June). What hath research wrought:  evaluating knowledge transfer of NSSI via online news media. Symposium:  new millennium media & non-​ suicidal self-​ injury. implications for mental health professionals. Paper presented at:  Canadian Psychological Association Annual Convention, Halifax, NS, Canada. Sternudd, H. T. (2012). Photographs of self-​injury: Production and reception in a group of self-​injurers. Journal of Youth Injurers, 15, 421–​436. Swannell, S., Martin, G., Krysinska, K., Kay, T., Olsson, K., & Win, A. (2010). Cutting on-​ line: Self-​injury and the Internet. Advances in Mental Health, 9, 177–​189. Washburn, J. J., Richardt, S. R., Styer, D. M., Gebhardt, M., Juzwin, K. R., Yourek, A., & Aldridge, D. (2012). Psychotherapeutic approaches to non-​suicidal self-​injury in adolescents. Child and Adolescent Psychiatry and Mental Health, 6, 14. Whitlock, J.  L., Lader, W., & Conterio, K. (2007). The Internet and self-​injury:  What psychotherapists should know. Journal of Clinical Psychology, 63, 1135–​1143. Whitlock, J.  L., Powers, J.  L., & Eckenrode, J. (2006). The virtual cutting edge:  The Internet and adolescent self-​injury. Developmental Psychology, 42, 407–​417. doi:10.1037/​ 0012-​1649.42.3.407. Zdanow, C., & Wright, B. (2012). The representation of self injury and suicide on emo social networking groups. African Sociological Review/​Revue Africaine de Sociologie, 16, 81–​101.

Chapter 13

Prevention of Nonsuicidal Self-​I njury Kaylee P. Kruzan and Janis Whitlock

Introduction While knowledge of NSSI risk factors and etiology has improved considerably over the past decade, development of evidence-​based approaches for NSSI prevention remains nascent. Indeed, there exists only one evidence-​based NSSI prevention approach, Signs of Self-​Injury (SOSI; Jacobs, Walsh, McDade, & Pigeon, 2009). Given the ubiquity of NSSI in youth and adolescent populations (De Silva, Parker, Purcell, Callahan, Liu & Hetrick, 2013; Heath, Toste, & MacPhee, 2010), this paucity is notable. Some prevention programs include information related to NSSI along with other high-​r isk behaviors, but empirical assessment of such approaches have not shown evidence of reductions in self-​injury behaviors (Eposito-​Smythers, Hadley, Curby, & Brown, 2017). In light of the dearth of programs to review, in this chapter we will suggest (like others; see:  Cox & Levine, 2014; Heath et  al., 2010; Whitlock & Knox, 2009) that comprehensive efforts to prevent NSSI must draw from best-​practice guidance in the prevention literature more generally. We first provide an overview of key prevention concepts followed by a summary of extant empirical research on NSSI and other areas relevant to NSSI prevention. We conclude with a summary of recommendations for applying skill and growth-​oriented approaches to NSSI prevention as well as recommendations for advancing research in this area.

Key Concepts in Prevention Preventing ill health is the backbone of virtually all public health paradigms and initiatives. As an expanding field, there is already ample support for the efficacy of prevention programs targeting mental health issues (Durlak & Wells, 1997; Heath et  al., 2010). Although a reasonably simple concept, the mechanics of prevention can be quite complex. Prevention efforts are comprised of multiple, often iterative, considerations related to: (1) prevention level, (2) target population (3) timing of intervention, and (4) venue. As clear identification of, and

216  Kaylee P. Kruzan and Janis Whitlock

approaches to, these elements have to be considered prior to any prevention effort, a review of salient elements follows. Prevention Level and Target Prevention efforts are usually characterized as either (1)  primary, aiming to stop behavior before it starts, (2) secondary, aiming to delay onset of problem behavior, or (3)  tertiary, a form of early intervention that aims to attenuate effects of problem behavior after it has already occurred (Durlak, 1997; Heath et al., 2010, p. 398). In general, references to “prevention projects” in media and in the literature most often signal tertiary prevention approaches, but may also refer to secondary prevention efforts in which a particular at-​risk population receives a program intended to stop or delay the onset of a condition they are otherwise likely to develop. Intrinsically linked to the question of prevention level is the question of who to include in the initiative. Corresponding to the levels referenced above, the three most common options in deciding who to target include: (1) universal (everyone in the specified setting, such as school), (2) targeted (a specific subpopulation based on demographics or risk level), and (3) stepped programs, which are a hybrid of both (Black & Threlfall, 1986). Population, geography, and myriad contextual factors drive decisions about prevention level and target. For example, universal programs, most often focused on primary prevention, are delivered broadly to an entire population and are often intended to increase competence and protective factors among individuals, regardless of their specific risk level (Durlak & Wells, 1997).These programs may focus on enhancing skills likely to mitigate the risk (e.g., cognitive flexibility and emotion regulation) of developing a specific condition of interest such as a skills-​based training implemented in a school-​wide health curriculum. Universal prevention efforts can be effective, but are often less efficacious than targeted secondary prevention approaches when seeking to reduce risk for particular conditions, such as self-​injury. Targeted interventions focused on individuals identified as high-​r isk often have larger effect sizes, relative to universal programs (Werner-​Seidler, Perry, Calear, Newby, & Christensen, 2017). Prevention programs may aim to teach emotion regulation strategies to a group of at-​r isk youth enrolled in an after-​school community program, for example. Stepped programs capitalize on the benefits of both of the aforementioned formats in which universal efforts are undertaken and followed by targeted efforts for individuals at risk based on assessments delivered at the end of the first step (Werner-​Seidler et al., 2017). Of course, delivery models have various strengths and trade-​offs. For example, secondary prevention with targeted populations tend to have higher effect sizes when compared to primary prevention efforts with the entire (universal) population, such as whole schools (Calear & Christensen, 2010; Merry et al., 2011; Werner-​Seidler et al., 2017). However, some scholars note that this difference in effect size may reflect the challenges in obtaining a large enough sample to

Prevention of Nonsuicidal Self-Injury  217

detect conditions in a universal sample, rather than superior efficacy of targeted interventions per se (Muñoz, Cuijpers, Smit, Barrera, & Leykin, 2010; Werner-​ Seidler et  al., 2017). Furthermore, what universal programs lack in potency may be offset by their unique contributions, namely: (1) no need for screening, (2)  minimization of stigma, and (3)  capturing youth who are not yet at risk (Werner-​Seidler et al., 2017). To date, most of the work on NSSI has focused on tertiary prevention or early intervention (secondary prevention) (Heath et al., 2010). However, the growing prevalence of NSSI, coupled with research documenting the potential contagion of this behavior through peer-​g roup exposure and media (Jarvi, Jackson, Swenson, Crawford, 2013), highlights the need for prevention approaches aimed at reducing likelihood of NSSI onset in whole populations (such as youth in school settings) or among those at elevated risk due to demographic risk factors, history of trauma, or chronic stress. Beyond Primary Targets: Engaging Social Ecologies When considering the primary target of intervention, youth for instance, it is also useful to consider how prevention efforts can leverage the larger social ecology to reinforce and amplify messages. Ecological approaches to prevention typically engage multiple levels of the primary target’s social ecology, such as parents, school administrators, teachers, or peers, as part of the prevention program (Jason & Rhodes, 1989; Klingman & Hochdorf, 1993). Mechanisms by which social environments influence behavior include (1) shaping of norms, (2) providing social reinforcement of behaviors, (3) providing opportunities to engage in behaviors, and (4)  facilitating or inhibiting the antecedents of the behaviors (Kawachi & Berkman, 2000). Involving gatekeepers, such as parents and peers, and considering the socio-​ecological environment in which NSSI behaviors manifest may be particularly efficacious. In support of this, adolescents identify access to non-​judgmental persons as useful to the prevention of NSSI behaviors (Fortune et  al., 2008; Muehlenkamp, Walsh, & McDale, 2010). Furthermore, when delivered in the school system, past research has shown that bringing in professionals from the community, rather than implementing the program through existing school staff, is associated with greater prevention effects, perhaps because messages and skill enhancement efforts are reinforced across various contexts (Calear & Christensen, 2010; Stallard et al., 2014;Werner-​ Seidler et al., 2017). Timing and Venue The timing of prevention efforts is likely to be critical to their success.Whitlock and Knox (2009) emphasize the importance of matching prevention or intervention programs to the group’s developmental stage. Because typical onset of NSSI is in early adolescence (12–​14 years) programs developed for implementation

218  Kaylee P. Kruzan and Janis Whitlock

in middle-​school settings may be particularly useful (Jacobson & Gould, 2007). Indeed, Heath et al. (2010) recommend that NSSI prevention efforts be directed towards upper elementary and middle school audience due to high onset rate of NSSI behaviors at this age and the number of hours individuals spend in school. Like considerations related to timing, deciding where (in what venue) prevention efforts are targeted and delivered is significant. As previously stated, existing literature suggests that behaviors that emerge in youth are best addressed in school-​based prevention programs (Heath et al., 2010). However, with advances in technology and the proliferation of mobile access, mobile and web-​based prevention efforts are becoming more common and promising alternatives when traditional modalities are inaccessible or ineffective with a given population (Kass et  al., 2014; Levin, Pistorello, Hayes, Seeley, & Levin, 2015). Because of the novelty of online initiatives, research on the efficacy of such interventions is limited, however their potential is well-​documented (Ebert, Cuijpers, Muñoz, & Baumeister, 2017; Sander, Rausch, & Baumeister, 2016). Adolescents spend a lot of time online and one-​third of youth with a history of NSSI report online help-​seeking (Frost & Casey, 2016). Therefore, researchers and practitioners in prevention science should consider adapting successful prevention efforts to online, mobile formats which can be used in a stand-​alone approach, part of stepped care, or blended into a traditional face-​ to-​face approach (Eberts et al., 2017). Pedagogy Pedagogy is the approach that individuals, such as teachers, or institutions such as schools, use to meet specific teaching/​learning objectives. These objectives are most often articulated as acquisition of knowledge (e.g., “as a result of this program, learners will demonstrate understanding of why individuals self-​ injure”), specific skills one hopes to have mastered (“as a result of this program, learners will demonstrate enhanced ability to communicate feelings verbally or in written form”), or something more subtle, like the influencing of norms and other implicit schemas that learners view the world through (“as a result of this program, learners will show increased acceptance of seeking help for emotional distress”). Often pedagogy is referred to with regards to specific learning and teaching strategies, which may range from didactic (e.g., a teacher conveying information and students demonstrating that they understand what was conveyed) to significantly more interactive (e.g., learners work in teams to produce something that requires them to use what they are learning, such as creating posters to be placed in common areas that encourage help-​seeking when distressed). Along with variation in the ways that learners are engaged, there may be variation in the ways that information or skills are conveyed. For example, students may be asked to listen to a teacher speaking about a topic and to watch interactive videos at home. These videos may involve social modeling or demonstrations of how to enact the specific skills they are learning (e.g., a

Prevention of Nonsuicidal Self-Injury  219

video of a young person disclosing their distress to an adult). Such strategies are best informed by theories of learning, understanding of the target audience and their developmental needs and capacities, as well as the fundamental objectives of the program.

Known Risk and Protective Factors Identifying prevention and early intervention targets will be most effective when tacked to risk factors and skill needs that are specific to NSSI. While some risk factors, such as those rooted in biological or neurological origins, may not be readily mutable through most common prevention approaches, enhancing skills and understanding related to most of the common individual and social level risk factors can be helpful. Indeed, because most of the underlying mechanisms identified are transdiagnostic, universal delivery of content intended to increase self-​awareness and enhance skills are likely to have broad appeal. Moreover, many of these domains are already represented in general mental health prevention and promotion programs as many primary prevention programs for youth, regardless of the focus of the intervention, aim to train individual-​level skills (e.g., resilience, coping skills, mindfulness) that enhance wellbeing and reduce risk behaviors or factors (Cox & Levine, 2014; Whitlock & Knox, 2009). Individual Level/​P sychological Contributors Effective approaches are those likely to address the functions NSSI comes to fill before NSSI becomes the go-​to behavior for feeling better. Research suggests that self-​injury occurs for several primary reasons:  to regulate and manage painful inner emotional turmoil, to communicate and express psychological distress, and to refocus one’s attention away from painful situations (for summary of most common function models, see Haskings,Whitlock,Voon & Rose, 2017). This desire to avoid or escape strong feelings, also called experiential avoidance, highlights the role self-​injury plays in reducing or stopping unwanted emotions. This pattern can become very cyclical and can foster a sense of shame and/​or failure, a path that tends to undermine long-​term sense of self-​worth and self-​ efficacy over time (Hasking et al., 2017). Emotion Regulation Individuals who self-​injure often feel emotions strongly and have trouble regulating these feelings. Indeed, difficulty with emotion regulation is the most commonly cited reason for self-​injury (Chapman, Gratz & Brown, 2006; Glenn, Blumenthal, Klonsky, & Hajcak, 2011). There are several components to this process, all articulated in the Cognitive-​Emotional Model for NSSI (CEM-​ NSSI; Hasking et  al., 2017), with implications for prevention. More specifically, with regard to emotion regulation, the model identifies that individuals

220  Kaylee P. Kruzan and Janis Whitlock

with predisposing biological and/​or early childhood factors are at high risk for NSSI when they possess: (a) higher than usual emotional reactivity to stimuli; (b) strong need to avoid the emotional experience; (c) lack of equally satisfying coping strategies; and (d) lower than usual tolerance for experiencing positive emotions (Hasking et al., 2017). The CEM-​NSSI also suggests that NSSI may provide a sense of control and/​or agency in response to diffuse or confusing emotions. Thus, approaches that incorporate awareness and skill building in emotion recognition, acceptance, and regulation are more likely to be effective. Self-​Compassion Findings related to challenges in perceiving and absorbing positive emotion (Allen & Hooley, 2015) are notable, because they suggest that individuals who injure would benefit not only from understanding how to anticipate, label, and diffuse negative emotions, but also how to perceive and allow in positive emotions. Research has shown that some individuals have fears and resistance to compassionate or soothing feelings toward themselves and have difficulties receiving warm gestures from others (Gilbert, 2009). Indeed, NSSI has been associated with a fear of compassion as well as high levels of shame and self-​ criticism (Gilbert, 2010; Xavier, Gouveia, & Cunha, 2016). Not surprisingly, then, self-​compassion, or being kind and understanding towards oneself, is seen as an indicator of positive psychological functioning and a protective factor against NSSI (Barnard & Curry, 2011; Xavier, Gouveia, & Cunha, 2016). Self-​ compassion involves self-​ directed kindness, a sense of common humanity, and mindfulness, and it combats against harmful self-​ judgment, isolation, and overidentification (Xavier et  al., 2016). Preliminary work shows that the relationship between NSSI, interpersonal difficulties, and depressive symptoms is moderated by self-​ compassion, suggesting that self-​ compassion buffers the influence and magnitude of external and internal triggers on NSSI behavior. Thus, in the context of prevention, efforts to attenuate negative feelings of guilt or shame as well as increase one’s sense of worthiness, such as compassion-​focused and mindfulness-​based approaches, may be particularly beneficial. Distress Tolerance Related to challenges in emotional perception and regulation domains, research suggests that individuals who self-​injure are less able (or less willing) to tolerate stress and distress than their non-​self-​injuring peers and that they use self-​injury as a method of escaping a distressing experience (Chapman, Gratz, & Brown, 2006; Nock & Mendes, 2008). When compared to individuals with a history of, but no current, NSSI behaviors, individuals with current NSSI behaviors report increased frustration and physiological arousal as well as greater difficulties solving problems upon being told that their answers to a card-​sorting

Prevention of Nonsuicidal Self-Injury  221

task were incorrect (Nock & Mendes, 2008). This is important because it offers hope that learning to accept and tolerate difficult feelings is a skill that can be developed and help in stopping the self-​injury cycle. Negative Cognition and Self-​Schemas In addition to difficulties with emotion, the CEM-​ NSSI rests on research that suggests that risk of NSSI is heightened by the presence of negative self-​ schemas and a tendency to overinterpret negative stimuli and diminish positive stimuli (Hasking et al., 2017). Because these factors are known to shape sense of self-​regard and the narratives one holds about one’s self and life (self-​schemas) (Linehan, 1993), approaches that raise self-​awareness about existing schemas, teach individuals to reframe existing negative self-​schemas or interpretations, and assist in teaching how to more consciously direct attention away from negative interpretations and toward those with kinder treatments of oneself will be helpful. Expectancies and Self-​Efficacy The CEM and other research (see Hasking et al., 2017 for review) increasingly point to the role that self-​efficacy plays in perpetuating NSSI, particularly when coupled with expectancies related to the efficacy of NSSI in reducing arousal. Believing that NSSI will be effective in achieving desired downregulation goals will increase risk of adopting and maintaining the behavior. Such expectancies can come from familiarity with the practice, either through direct exposure from peers or indirect exposure through media (Whitlock, Purington, & Gershkovich, 2009). Coupled with low sense of efficacy in staying away from the behavior when in stress, this may increase likelihood of relapse. While this dynamic has more obvious implications for early intervention (increase self-​efficacy related to ability to resist NSSI), prevention efforts focused on emphasizing how ineffective using strategies like NSSI are in reducing arousal may be helpful. Relatedly, hopelessness has been identified as a risk factor for NSSI. Exercises aimed at building self-​efficacy can be useful in developing confidence and resilience in the face of future challenges (Brown & Plener, 2017). Body Image and Regard In addition to emotion regulation, research suggests that body-​image and regard, or how an individual experiences the body, may be important to consider in NSSI prevention efforts. Research has shown that body disregard and negative evaluations of the body are associated with NSSI risk (Muehlenkamp & Brausch, 2012). Moreover, Muehlenkamp claims that body disregard is a necessary –​but not sufficient –​antecedent that facilitates the development of NSSI behavior. Body regard is defined as “one’s protective attitudes, actions, and feelings towards the body” (Muehlenkamp, 2012, p. 332).This includes perceived

222  Kaylee P. Kruzan and Janis Whitlock

physical and sensorimotor functioning and one’s “connection to, ownership of, and understanding of the body” (Muehlenkamp, 2012, p. 332). Conversely, body disregard, most often associated with eating disorders, is theorized to play an important role in NSSI. Numerous studies have shown that individuals with NSSI report high levels of body objectification, dissociation, and body disregard (Muehlenkamp, 2012, p. 333; Favaro, Ferrara, & Santonastaso, 2007; Nelson & Muehlenkamp, 2012). The close and complicated relationship between the experience of the body and NSSI onset is not surprising when considering that NSSI behaviors are often used to “regulate emotional imbalance and to communicate distress to the self or others” –​and clinical experience with NSSI shows that “it gives form and expression to discomfort with physical changes and sexual impulses, confusion about the twin need for autonomy and connection,” for example (Whitlock & Knox, 2009, p.  176). Thus, addressing adolescents’ understanding of, and relationship to, their changing bodies appears to be an important aspect of any program aiming to diminish NSSI development. Social Contributors Social models of self-​injury view self-​injury as a behavior that is undertaken to seek out social connection or attention. In other words, engaging in self-​injury serves as a coping strategy that helps to either gain control over, or escape from, perceived social demands (Hasking et  al., 2017). Several specific motivations may be at play including a desire to communicate distress to others, a desire for connection, or a desire to avoid unwanted social situations. It is important to note, however, that self-​injury is rarely undertaken for merely theatrical purposes or group membership (e.g., “trying to fit in”). To dismiss self-​injury as merely attention-​seeking or simply as a way to belong is far less useful than recognizing that it may fundamentally signal the need for developing healthy communication skills and managing emotions that result from interpersonal exchange. The Role of Peers Although we know that it is most common for individuals with regular, even if intermittent, self-​injury to report injuring as a means of regulating negative emotion, approximately 15–​30% of adolescents and young adults identify social reasons for doing it, usually as a bid for communicating pain or hurt or to convey a desire for connection (Muehlenkamp, Brausch, Quigley & Whitlock, 2013). Applied to self-​injury, the social signaling hypothesis suggests that self-​injury helps to facilitate social communication as a “high-​intensity” behavior (Darosh & Lloyd-​ Richardson, 2013; Nock, 2009). In this way, it may fulfill multiple functions simultaneously, many of which are fundamentally interpersonal in nature (Heath, Ross, Toste, Charlebois, & Nedecheva, 2009; Muehlenkamp et al., 2013). Not surprisingly, then, it is important to note that the most common triggers for NSSI are interpersonal exchanges, largely because they lead to

Prevention of Nonsuicidal Self-Injury  223

perceptions of rejection, failure and disappointment (Muehlenkamp et  al., 2013). Notably, social triggers can also be replayed internally, meaning that memories or associations of triggering social events can initiate a chain of feelings and thoughts that result in a desire to self-​injure. These triggers can arise as a result of memories or other unobvious associations that are visited or encountered in the course of daily life, as well. Lastly, self-​injury can become both compulsive and so habitual that the desire to injure may occur independent of a clear external triggering event (Nock & Favazza, 2009;Whitlock & Selekman, 2014). From a prevention perspective, this underscores the important protective function of healthy, supportive interpersonal bonds and furthers assertions in the literature for emphasizing social and familial support (Muehlenkamp et al., 2013). Bullying Other social factors such as dysfunctional relationships and a history of bullying have been identified as risk factors for the development of NSSI (Brown & Plener, 2017). Indeed, a recent meta-​analysis found that adolescents with a history of bullying victimization were twice as likely to report engaging in NSSI than their non-​victimized counterparts (Baiden, Stewart, & Fallon, 2017; van Geel, Goemans & Vedder, 2015).When viewed through the lens of vulnerability-​ stress theory (Hankin & Abela, 2005), peer victimization is seen as an adverse event that places individuals at risk for psychopathology and future adverse events, in a cyclical fashion (Baiden et  al., 2017, p.  239). Research reveals a dose–​response relationship between peer victimization and NSSI and suicidal behaviors (Jantzer, Haffner, Parzer, Resch, & Kaess, 2015), suggesting that early intervention is critical to future mental health outcomes. Given that the majority of bullying in youth and adolescent populations occurs in school settings, these findings highlight the importance of cultivating a sense of trust and perceived safety within the school ecology, including the implementation of consistent protocols for intervening in bullying behavior early on (Arseneault, Bowes, & Shakoor, 2010; Noble et  al., 2011). Familial support has been shown to buffer the negative consequences of bullying by moderating the relationship between victimization and NSSI behavior (Claes, Luyckx, Baetens,Van de Ven & Witteman, 2015; Jantzer et al., 2015). In light of this evidence, Baiden et al. (2017) suggest a two-​pronged approach to NSSI prevention including universal efforts to enhance protective factors and strengthen the general morale and trust within the larger system (e.g., school) and targeted efforts using bullying history as an indicator of risk. Contagion Youth with persistent emotional distress are likely to be drawn to peers who engage in self-​injury as well as to media that feature or include NSSI. In some

224  Kaylee P. Kruzan and Janis Whitlock

cases, youth who are socially disconnected, isolated, and alienated may be especially drawn to similarly alienated peers (Prinstein et al., 2010). Not surprisingly, both research and anecdotal studies suggest that self-​injury can and sometimes does “spread” among youth (and adults) (Jarvi, Jackson, Swenson, & Crawford, 2013). Social contagion episodes have been reported among adolescents and adults in schools and other institutions, such as inpatient treatment settings, group homes, prison and juvenile detention facilities. Moreover, the spread of self-​injury does not only occur among those who know each other.Widespread introduction and spread of self-​injury in mainstream media as well as in virtual venues (e.g., through the internet or other digitally mediated communities) has also led to contagion (Jarvi et al., 2013). The implications for prevention and early intervention are several. From a prevention standpoint, if we understand that for many people self-​injury may serve as a bid for interpersonal connection, then investing in prevention programs that focus on cultivating authentic and meaningful interpersonal relationships will be most helpful. When enacted in schools or other institutional settings, these kinds of programs are often useful in also cultivating higher levels of connectedness and sense of belonging and are typically helpful in reducing risk factors for a variety of negative outcomes. While prevention efforts should be effective in thwarting contagion before it starts, if NSSI is already active within the institution, it is useful to incorporate approaches that identify and meaningfully address the needs of individuals most active in spreading the behavior (see strategies in Hasking et al., 2016). The Role of Parents When young people are the target of the intervention, it is useful to think about constructive ways to engage parents. Etiological studies suggest that NSSI stems from a complex developmental process, which includes perception of the social environment as invalidating (Sim, Adrian, Zeman, Cassano, & Friedrich, 2009; Wedig & Nock, 2007). Family factors including perceived parental criticism (Wedig & Nock, 2007), negative responses to children’s emotional expressivity (Sim et  al., 2009; Wedig & Nock, 2007), poor communication (Oldershaw, Richards, Simic, & Schmidt, 2008), and parent–​child discord (Oldershaw et al., 2008) are associated with development of NSSI in youth. Clinicians recognize parents as important contributors to the child’s recovery process (Hoagwood et  al., 2010) for several reasons:  (1) parental emotion regulation, expressivity, cognitions (about themselves, their child, and parenting), and communication capacity are strongly implicated in NSSI etiology; and (2) youth learn emotion regulation and communication skills from parents, both directly via parent–​child interactions and indirectly as parents model these competencies (Morris, Silk, Steinberg, Myers, & Robinson, 2007). Because family support is a significant predictor of whether a young person starts and/​or ceases their self-​injury, actively involving families in prevention

Prevention of Nonsuicidal Self-Injury  225

and early intervention efforts may be very fruitful (Tatnell, Kelada, Hasking, & Martin, 2014; Whitlock, Prussien, & Pietrusza, 2015). Extant research identifies three salient factors: youth’s perceived alienation in the family context, perceived criticism, and disconnectedness from others, particularly parents (Baetens et  al., 2014; Di Pierro, Sarno, Perego, Gallucci, & Madeddu, 2012; Giletta et  al., 2012; Muehlenkamp, Brausch, Quigley, & Whitlock, 2013). Because of this, efforts to engage parents would ideally be aimed at assisting them in understanding how to connect and interact with their child in ways that enhance the likelihood that their child will perceive the connection and view the interactions as communicating care, regard, and acceptance. These efforts should also capitalize on parental/​caretaker influence as role models who, through direct and indirect means, demonstrate how to express and discharge emotion in productive ways.

Putting It All Together: Promising Approaches in NSSI Prevention While there is only one prevention program specifically designed to target NSSI behaviors, there are several programs that train and educate on risks and protective factors relevant to mental health. In so doing, these programs tap into some of the critical individual (emotion regulation, distress tolerance, negative cognition and schemes, expectancies and self-​efficacy, body image and regard) and social (peers, contagion, parents) elements identified for prevention of NSSI discussed thus far. Successful prevention programs are likely to tap into many of these elements and to be ecologically and modality diverse. One approach to building a robust prevention initiative is to draw on the strengths of existing programs in training individual or social elements. The Signs of Self-​Injury (SOSI) Program (Jacobs et  al., 2009) is the only existing program for NSSI prevention. SOSI is a school-​ based prevention program designed to increase awareness of NSSI warning signs and symptoms and encourage help-​seeking behaviors. Specifically, the program aims include (a) increasing knowledge of NSSI, (b) improving attitudes and perceived capability to respond and help refer students, or peers, who engage in NSSI, (c) increasing help-​seeking behaviors for NSSI for peers or self, and (d)  decreasing acts of NSSI among adolescents (Muehlenkamp et  al., 2010, p.  307). The program can be delivered as a universal tertiary prevention or targeted approach and is implemented by trained school faculty and staff. Faculty and staff receive a brief psychoeducational training which emphasizes NSSI warning signs and guidelines for school policy, and students participate in a 50-​minute classroom session that uses video vignettes to demonstrate how to respond to peers who self-​injure and what a meeting with an individual who self-​injures might look like (Andover et  al., 2014; Jacobs et  al., 2009). At the closing of this session students are given a risk for self-​injury assessment and are asked to mark one of two statements: “I need to talk to someone,” or “I do not need to talk to

226  Kaylee P. Kruzan and Janis Whitlock

someone.” Students who mark that they need to talk are then contacted by a psychologist at follow-​up (Jacobs et al., 2009). Although no summative evaluation of SOSI has been conducted, Muehlenkamp et  al. (2010) conducted a feasibility test of this program at five schools. One school delivered the program universally, through the core health curriculum, and the other four targeted the program to students with behavioral or emotional difficulties. Results suggest that the program increased (1)  knowledge of NSSI, (2)  openness to help-​seeking for peers, and (3)  decreased discomfort or avoidance (Muehlenkamp et  al., 2010). Additionally, there were no signs of iatrogenic effect and at a five-​week follow-​ up there was decrease (nonsignificant) in acts of NSSI (Muehlenkamp et al., 2010). While psychoeducation provided to school professionals and students may reduce expectancy outcomes related to NSSI, SOSI is a tertiary prevention program aimed at helping individuals identify existing cases of NSSI, rather than preventing the onset of such behaviors. Preliminary work suggests the promise of SOSI, but evidence is limited. Other school-​wide approaches to NSSI prevention and early intervention are emerging but similarly underevaluated. For example, the HAPPYLES program, an evidence-​based, brief cognitive-​behavioral skills program designed for at-​r isk youth (der Zanden & Van der Linden, 2013), was adapted by Imke Baetens and colleagues to improve psychological well-​being, coping and to reduce stigma, and as a consequence reduce NSSI severity and onset. The HAPPYLES program includes classroom-​based delivery of four prevention lessons (two are face-​to-​f ace classroom discussions and interactive assignments and two are guided e-​health lessons) and a 10-​minute individual interview with each student at the end of the program followed by referrals to mental health providers as needed. In a recent randomized controlled trial study (publications in process), both the original HAPPYLES program and a version of the program which included an extra lesson on self-​care and prevention of self-​injury (HAPPYLES+; in which a documentary for the prevention of self-​ injury was shown, followed by a class discussion on handling NSSI in social media, seeking help, and attitudes towards self-​injury) was found to increase general well-​being and to reduce depressive symptoms. Students receiving HAPPYLES+ reported reduced physical complaints and increased emotional awareness. The biggest benefit accruing to students with self-​reported mental health symptoms at baseline measurement and individuals with self-​injury experience was reduced bullying, increased social support and hope for the future, and increased understanding of how they can help a friend who is self-​injuring. Like the SOSI program, HAPPYLES is in alignment with NSSI scholar assertions that intervention efforts should include psychoeducation aimed at increasing awareness of NSSI and stopping the spread of contagion in schools (Jarvi et al., 2013). In addition to awareness and early intervention, another promising approach has been to target school or community norms and increase socioecological

Prevention of Nonsuicidal Self-Injury  227

protective factors. For example, the Sources of Strength (SOS) program is an evidence-​based suicide prevention program that relies on peer networks and leaders, and connections between peers and key adults to identify and intervene with students showing signs of distress and risk for suicide (LoMurray, 2005; Wyman et al., 2010). A key component of the SOS program is the identification and training of opinion leaders in a given population to change descriptive (e.g., what is perceived of as typical behavior) and injunctive (e.g., social consequences of behavior) norms around suicide ideation and behavior (Wyman et al., 2010, p. 1654).The program is typically implemented in three phases: (1) school staff and community preparation, (2) training peer leaders, and (3) school-​wide messaging. Preparation includes 4–​6 hours of staff training on how to advise peers leaders. Peer leaders undergo four hours of interactive training with modules on eight protective factors as well as how to engage trusted adults. The last phase includes deployment of messaging on social networks, video, and text. By recruiting peer leaders and emphasizing the role of reaching out to trusted adults, this program has had success in changing norms associated with the acceptability of help-​seeking and the capacity of adults in their school system to help individuals with suicidal behavior. Importantly, increases in perceptions of adult help was strongest for those with a history of suicidal ideation  –​which is promising because such support has been empirically linked to reduced risk behavior. SOS’s success with suicide has resulted in an expanded set of trials looking at efficacy for other outcomes, including, but not limited to, sexual violence prevention. Although nonsuicidal self-​injury has not been a target area for Sources of Strength, engagement of multiple elements of the social ecology and its focus on stigma reduction and early intervention are components likely to be effective in NSSI reduction as well. Other programs have been designed to promote well-​being and resiliency more generally through the training of protective skills. For example, DBT Skill Training for Emotional Problem Solving for Adolescents (DBT STEPS-​A) is a universal prevention effort designed to teach adolescents DBT skills in school settings (Mazza, Dexter-​Mazza, Miller, Rathus, & Murphy, 2016). The program is comprised of modules on four key DBT skills including:  mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness (Mazza & Dexter-​Mazza, 2017). Prior work has shown that these skills are associated with reductions in NSSI and STB in high-​r isk youth (Mazza & Hanson, 2015). The curriculum is comprised of 30 structured lesson plans which each include: (1) mindfulness exercises or activities, (2) dyadic, peer review of skill-​based homework, (3) lessons on new skills, and (4) homework to practice skills outside of the classroom. Reviewing homework in peer dyads provides students with an opportunity to discuss challenges with their classmates and may increase the likelihood of them disclosing issues via more informal interactions. Progress is monitored through the use of diary cards on which students report daily use and effectiveness of implemented skills. While the program was designed to be delivered universally, it can be supplemented to meet the needs of individuals with previously identified mental

228  Kaylee P. Kruzan and Janis Whitlock

health issues through a multi-​tiered system of support. Such adaptations may include individual mentorship, smaller class sizes, or re-​cycling through certain material or modules. The program is relatively new so there is a need for formal research on its efficacy. However, preliminary research shows that the program is associated with improvements in coping strategies, reductions in emotion symptoms, and increases in self-​esteem (Mazza & Dexter-​Mazza, 2017). Another universal program, Learning to Breathe, focuses on training social–​ emotional learning skills among middle and high school students (Metz et  al., 2013). Primary components of the program include emotion regulation and attentional skills rooted in mindfulness practices. The program is implemented in health classes across six 45-​minute sessions and delivered by health teachers with mindfulness-​based stress reduction training. The content of these six sessions include:  (1) body awareness; (2)  understanding and working with thoughts; (3) understanding and working with feelings; (4) integrating awareness of thoughts, feelings and body sensations; (5) reducing harmful self-​judgments; and (6) integrating mindful awareness into daily life. Each session includes a lesson, guided discussion, and in-​class practices. Feasibility and efficacy trials show improvement on self-​regulation, perceived efficacy, psychosomatic complaints, and stress. However, the program did not improve impulse control or emotional reactivity. The Strong Kids program, part of the Oregon Resiliency Initiative (ORI), similarly focuses on skills training through a curriculum with five key areas of emotional competency: (1) self-​awareness; (2) self-​management; (3) social awareness; (4) relationship skills; and (5) responsible decision making (Merrell 2010, pp. 55–​ 56). The program has been delivered to students from pre-​kindergarten through high school age and can be taught by a broad range of professionals, including school staff or outside professionals. Evaluations of this program show promise for psychoeducation including increasing knowledge of self-​injury behavior, reducing self-​reported internalizing problem symptoms (Isava, 2006; Kramer, Caldarella, Christensen, & Shatzer, 2010; Merrell, Juskelis, Tran, & Buchanan, 2008) and increasing self-​reported social-​emotional competence and resilience (Harlacher & Merrell, 2010; Kramer et al., 2010). Additionally, treatment gains were maintained at short-​term follow-​up in a number of studies (Harlacher & Merrell, 2010; Marchant, Brown, Caldarella & Young, 2010). Finally, a new line of work suggests the benefits of compassion training for youth and adolescents’ emotion regulation and preliminary work shows that compassion may prevent shame, guilt, and stigma associated with problematic behaviors (Van Vliet & Kalnins, 2011; Xavier, Gouveia, & Cunha, 2016). The Making Friends with Yourself: A Mindful Self-​Compassion Program for Teens (MFY), an adaptation of the adult Mindful Self-​Compassion program, has demonstrated meaningful results in self injury related conditions, such as anxiety and depression.The MFY program has been delivered as a six-​or eight-​ week class in schools focused on increasing capacity for mindfulness and self-​ compassion. It is typically delivered in a school setting, but can be delivered in other settings as well. For example, the six-​week program sessions last 90

Prevention of Nonsuicidal Self-Injury  229

minutes and are organized by themes including: (1) defining mindfulness and self-​compassion; (2) introduction to mindfulness practices; (3) understanding the teenage brain and brain development; (4) distinguishing self-​compassion from self-​esteem; (5) finding your compassionate voice (e.g., expression through art or writing); and (6) practicing gratitude. Each session includes hands-​on activities and weekly home practices are assigned. Preliminary trials evince reduced depression and anxiety as well as increased self-​compassion, life satisfaction, and social connectedness (Bluth, Gaylord, Campo, Mullarkey & Hobbs, 2016; Bluth & Eisenlohr-​Moul, 2017). The aforementioned programs have notably stronger emphases on either the social or individual ecologies. For example, the SOSI and SOS programs are based on a similar model training individuals to know how to get support when they are distressed, or when they have identified a peer in distress (Muehlenkamp, Walsh, McDade, 2010; SOSI), whereas the Learning to Breathe and Strong Kids programs take a protective approach and draw from social and emotional learning to build individual competency. The new HAPPYLES(+) program most effectively blends elements of both ecologies but evidence remains limited. If engaging multiple ecologies is crucial to the success of NSSI prevention, as the literature suggests (Heath et  al., 2010; Whitlock & Knox, 2009), then pulling elements from these models in order to develop a new, more robust program seems a viable step forward. Notably, parent and/​or family involvement is underrepresented across all programs and future efforts should seek to incorporate family support beyond consent to engage in the program. While the programs examined in this chapter have been predominantly implemented in school settings, researchers needn’t limit future program development to these confines. School programs are often convenient for accessing and delivering prevention to individuals in critical stages of development (e.g., youth, adolescence) and can tap into multiple ecologies; however, with the growing proliferation of technology in the home, and on the go, there is a growing interest in tech-​based prevention and early intervention efforts.

A Role for Technology in Prevention and Early Intervention? In light of the success of tech-​based interventions in treating a myriad of mental health issues including depression (Ebert et  al., 2015; Hedman, Ljótsson, & Lindefors, 2012), anxiety (Cuijpers et al., 2009; Mayo-​Wilson & Montgomery, 2013), and eating disorders (Bauer & Moessner, 2013; Gulec, Moessner, Mezei, Kohls, Túry & Bauer, 2011), tech-​assisted prevention emerges as a promising complement, or alternative, to traditional modalities due to their ability to transcend boundaries such as cost and accessibility. In general, tech-​based programs can be more cost-​effective and can reach individuals who live in geographically isolated areas. Additionally, research on social support and communication technologies suggests that online anonymity can promote freer expression of mental

newgenrtpdf

Table 13.1 Individual and Social Elements of Existing Prevention Programs Program Name

Main components

Signs of Self-​Injury

Psychoeducation for peers, early intervention

HAPPYLES(+) Cognitive behavioral skills, NSSI psychoeducation for peers and early intervention Sources of Psychoeducation Strength and training for peers, norms, early intervention DBT STEPS-​A DBT skills

Individual elements

Social elements

Emotion regulation

Self-​ Distress compassion/​ tolerance mindfulness-​ based

Negative cognition/​schemas (cognitive element)

Expectancies and self-​efficacy

Body image and regard

Peers Contagion Parents

_​

_​

X (Decreased avoidance)

_​

X

X

_​

X

_​

X

_​

X (increased _​ confidence in ability to respond) X _​

_​

_​

_​

_​

_​

_​

_​

X

_​

X

X

_​

X

X

X

X

X

_​

X

_​

X (Supple­ mental programs can include parents)

newgenrtpdf

Learning to Breathe Strong Kids

Skills, mindfulness

X

X

X

Skills, social and emotional learning

X

_​

X

Making Friends with Yourself

Skills, social and emotional learning/​focus on inner support rather than social support

X

X

Key X = program emphasis _​ = not emphasized in program

X

X (Emphasis on understanding and dealing with negative emotion) X (emphasized Unclear in 8-​week program)

X

X

_​

_​

_​

X

_​

_​

_​

_​

X

X (emphasis _​ on changes taking place during adolescence in session 3)

_​

_​

232  Kaylee P. Kruzan and Janis Whitlock

health issues by attenuating concerns around stigma (De Choudhury & De, 2014). In the context of prevention, technologies can be leveraged to reach individuals who may otherwise be hesitant to participate in programs due to stigma associated with mental health services (Walther & Boyd, 2002). In addition to the considerations for prevention described in this chapter (e.g., the type of prevention program, timing, content), several novel considerations emerge when utilizing technology including program implementation (which technologies to use) and the degree of human support necessary (e.g., self-​help, peer support) (Eberts et al., 2017). In a recent review, Ebert and colleagues (2017, p. 3) point to a number of technical possibilities that can be utilized for prevention, including: (1) self-​guided or assisted self-​help lessons; (2) virtual reality for exposure modules; (3) email, chat, or video sessions; (4) serious gaming (wherein psychological strategies are trained); (5) automated feedback and reinforcement of skill through apps, text messages or email; and (6) sensors for tracking health behavior. Perhaps the most profound affordance of technology for prevention is that lessons and content can be more seamlessly integrated into the daily lives of individuals. Because tech-​based prevention is a nascent area, there is limited evidence for program efficacy. Ebert and colleagues (2017) identified tech-​based prevention efforts aimed at attenuating risk for development of eating disorders (Lindenberg & Kordy, 2015; Taylor et al., 2016), anxiety disorders (Christensen, Mackinnon, Griffiths, Kalia Hehir, & Kenardy, 2014) and depression (Buntrock et al., 2017; Thompson et al., 2015), all with good to moderate success in delaying behavior onset. Notably, existing programs have focused on indicated or selected prevention in predominantly adult populations, so there is a need for evaluations of such programs in younger populations as well as more universal efforts. Given the ubiquity of technology use among adolescents, there is reason to believe that these programs would be well received.

Summary A growing understanding of the psychological profiles and contextual factors that indicate risk for the development of NSSI behaviors has paved the way for informed NSSI prevention efforts. This chapter reviewed best practice guidance from the prevention literature and empirical research on NSSI to provide guidance on NSSI prevention and program development. In sum, the literature points to several individual (emotion regulation, distress tolerance, negative cognition and schemes, expectancies and self-​efficacy, body image and regard) and social (peers, contagion, parents) elements that are likely to be important in NSSI prevention initiatives. This chapter goes on to highlight several existing programs with strengths in these areas. Notably, most programs have a dominant focus on one ecology. A robust prevention program is likely to draw from multiple modalities and ecologies.

Prevention of Nonsuicidal Self-Injury  233

References Allen, K.  J., & Hooley, J.  M. (2015). Inhibitory control in people who self-​ injure:  Evidence for impairment and enhancement. Psychiatry Research, 225(3), 631–​637. Andover, M. S., Wren, A., Schatten, H. T., Morris, B. W., Shashoua, M. Y., & Holman, C. S. (2014). Non-​suicidal self-​injury. In T. P. Gullotta, R. W. Plant, & M. Evans (Eds.). Handbook of adolescent behavioral problems:  Evidence-​based approaches to prevention and treatment. New York: Springer. Arseneault, L., Bowes, L., Shakoor, S., 2010. Bullying victimization in youths and mental health problems: ‘Much ado about nothing’? Psychological Medicine, 40(5), 717–​729. Baetens, I., Claes, L., Onghena, P., Grietens, H.,Van Leeuwen, K., Pieters, C., … Griffith, J.  W. (2014). Non-​suicidal self-​injury in adolescence:  A longitudinal study of the relationship between NSSI, psychological distress and perceived parenting. Journal of Adolescence, 37(6), 817–​826. Baiden, P., Stewart, S. L., & Fallon, B. (2017).The mediating effect of depressive symptoms on the relationship between bullying victimization and non-​suicidal self-​injury among adolescents: Findings from community and inpatient mental health settings in Ontario, Canada. Psychiatry Research, 255, 238–​247. Barnard, L.  K., & Curry, J.  F. (2011). Self-​compassion:  Conceptualizations, correlates, and interventions. Review of General Psychology, 15, 289–​303. doi:10.1037/​a0025754. Bauer, S. & Moessner, M. (2013). Harnessing the power of technology for the treatment and prevention of eating disorders. International Journal of Eating Disorders, 46(5), 508–​515. Black, D.  R., & Threlfall, W.  E. (1986). A stepped approach to weight control:  A ­minimal intervention and a bibliotherapy problem-​solving program. Behavior Therapy, 17(2), 144–​157. Bluth, K., & Eisenlohr-​Moul, T. A. (2017). Response to a mindful self-​compassion intervention in teens:  A within-​person association of mindfulness, self-​compassion, and emotional well-​being outcomes. Journal of Adolescence, 57, 108–​118. Bluth, K., Gaylord, S. A., Campo, R. A., Mullarkey, M. C., & Hobbs, L. (2016). Making friends with yourself:  A mixed methods pilot study of a mindful self-​compassion program for adolescents. Mindfulness, 7(2), 479–​492. Borrill, J., Fox, P., Flynn, M., & Roger, D. (2009). Students who self-​harm: Coping style, rumination and alexithymia. Counselling Psychology Quarterly, 22(4), 361–​372. Brent, D.  A., Moritz, G., Liotus, L., Schweers, J., Balach, L., Roth, C., & Perper, J.  A. (1998). Familial risk factors for adolescent suicide. In R.  J. Kosky, H.  S. Eshkevari, R. D. Goldney, & R. Hassan (Eds.), Suicide prevention: The global context (pp. 41–​50). New York: Plenum Press Brown, R.  C. & Plener, P.  L. (2017). Non-​suicidal self-​injury in adolescence. Current Psychiatry Reports, 19(3), 20. Buntrock, C., Berking, M., Smit, F., Lehr, D., Nobis, S., Riper, H., … Ebert, D. (2017). Preventing depression in adults with subthreshold depression: Health-​economic evaluation alongside a pragmatic randomized controlled trial of a web-​based intervention. Journal of Medical Internet Research, 19(1). Calear, A. L., & Christensen, H. (2010). Systematic review of school-​based prevention and early intervention programs for depression. Journal of Adolescence, 33, 429–​438. http://​dx.doi.org/​10.1016/​j.adolescence.2009.07.004.

234  Kaylee P. Kruzan and Janis Whitlock Claes, L., Luyckx, K., Baetens, I., Van de Ven, M., & Witteman, C. (2015). Bullying and victimization, depressive mood, and non-​suicidal self-​injury in adolescents: The moderating role of parental support. Journal of Child and Family Studies, 24(11), 3363–​3371. Chapman, A.  L., Gratz, K.  L., & Brown, M.  Z. (2006). Solving the puzzle of deliberate self-​harm: The experiential avoidance model. Behavior Research and Therapy, 44, 371–​394. Christensen, H., Batterham, P., Mackinnon, A., Griffiths, K. M., Hehir, K. K., Kenardy, J., … Bennett, K. (2014). Prevention of generalized anxiety disorder using a web intervention, iChill: Randomized controlled trial. Journal of Medical Internet Research, 16(9). Cox, L. J., & Levine, M. P. (2014). Prevention and postvention of NSSI and disordered eating. In L. Claes & J. J. Muehlenkamp (Eds.), Non-​suicidal self-​injury in eating disorders (pp. 295–​318). Berlin: Springer. Cuijpers, P., Marks, I.  M., van Straten, A., Cavanagh, K., Gega, L., & Andersson, G. (2009). Computer-​aided psychotherapy for anxiety disorders: A meta-​analytic review. Cognitive Behavior Therapy, 38(2), 66–​82. Darosh, A.  G., & Lloyd-​Richardson, E.  E. (2013, December). Exploring why students self-​injure: The functions of nonsuicidal self-​injury. In School Psychology Forum, 7(4). De Choudhury, M., & De, S. (2014, June). Mental health discourse on reddit:  Self-​ disclosure, social support, and anonymity. In Proceedings of the Eighth International AAAI Conference on Weblogs and Social Media. De Silva, S., Parker, A., Purcell, R., Callahan, P., Liu, P., & Hetrick, S. (2013). Mapping the evidence of prevention and intervention studies for suicidal and self-​harming behaviors in young people. Crisis, 34, 223–​232. https://​doi-​org.proxy.library.cornell. edu/​10.1027/​0227-​5910/​a000190. Di Pierro, R., Sarno, I., Perego, S., Gallucci, M., & Madeddu, F. (2012). Adolescent nonsuicidal self-​injury: The effects of personality traits, family relationships and maltreatment on the presence and severity of behaviors. European Child & Adolescent Psychiatry, 21(9), 511–​520. Durlak, J.  A. (1997). Successful prevention programs for children and adolescents. New  York: Plenum Press. Durlak, J. A., & Wells, A. M. (1997). Primary prevention mental health programs for children and adolescents: A meta-​analytic review. American Journal of Community Psychology, 25(2), 115–​152. Ebert, D. D., Cuijpers, P., Muñoz, R. F., & Baumeister, H. (2017). Prevention of mental health disorders using internet-​and mobile-​based interventions: A narrative review and recommendations for future research. Frontiers of Psychiatry, 8, 116. doi:10.3389/​ fpsyt.2017.00116 Ebert, D. D., Zarski, A. C., Christensen, H., Stikkelbroek,Y., Cuijpers, P., Berking, M., & Riper, H. (2015). Internet and computer-​based cognitive behavioral therapy for anxiety and depression in youth: A meta-​analysis of randomized controlled outcome trials. PLoS ONE, 10(3), e0119895. Esposito-​Smythers, C., Hadley, W., Curby, T. W., & Brown, L. K. (2017). Randomized pilot trial of a cognitive-​behavioral alcohol, self-​harm, and HIV prevention program for teens in mental health treatment. Behavior Research and Therapy, 89, 49–​56. Favaro, A., Ferrara, S., & Santonastaso, P. (2007). Self-​injurious behavior in a community sample of young women: Relationship with childhood abuse and other types of self-​damaging behaviors. The Journal of Clinical Psychiatry, 68(1), 122–​131.

Prevention of Nonsuicidal Self-Injury  235 Frost, M., & Casey, L. (2016). Who seeks help online for self-​injury? Archives of Suicide Research, 20(1), 69–​79. Fortune, S., Sinclair, J., & Hawton, K. (2008). Adolescents’ views on preventing self-​harm. Social Psychiatry and Psychiatric Epidemiology, 43(2), 96–​104. van Geel, M., Goemans, A., & Vedder, P. (2015). A meta-​analysis on the relation between peer victimization and adolescent non-​suicidal self-​injury. Psychiatry Research, 230(2), 364–​368. Gilbert, P. (2009). The compassionate mind:  A new approach to life’s challenges. London: Constable and Robinson. Gilbert, P. (2010). An introduction to compassion focused therapy in cognitive behavior therapy. International Journal of Cognitive Psychotherapy, 3, 97–​ 112. doi:10.1521/​ ijct.2010.3.2.97. Giletta, M., Scholte, R. H., Prinstein, M. J., Engels, R. C., Rabaglietti, E., & Burk, W. J. (2012). Friendship context matters: Examining the domain specificity of alcohol and depression socialization among adolescents. Journal of Abnormal Child Psychology, 40(7), 1027–​1043. Glenn, C. R., Blumenthal,T. D., Klonsky, E. D., & Hajcak, G. (2011). Emotional reactivity in nonsuicidal self-​ injury:  Divergence between self-​ report and startle measures. International Journal of Psychophysiology, 80(2), 166–​170. Gulec, H., Moessner, M., Mezei, A., Kohls, E., Túry, F., & Bauer, S. (2011). Internet-​based maintenance treatment for patients with eating disorders. Professional Psychology: Research and Practice, 42(6), 479–​486. Hankin, B. L., & Abela, J. R. Z. (2005). Depression from childhood through adolescence and adulthood: A developmental vulnerability–​stress perspective. In B. L. Hankin & J.  R.  Z. Abela (Eds.), Development of psychopathology:  A vulnerability–​stress perspective (pp. 245–​288). Thousand Oaks, CA: Sage. Harlacher, J. E., & Merrell, K. W. (2010). Social and emotional learning as a universal level of student support: Evaluating the follow-​up effect of strong kids on social and emotional outcomes. Journal of Applied School Psychology, 26(3), 212–​229. Hasking, P. A., Heath, N. L., Kaess, M., Lewis, S. P., Plener, P. L., Walsh, B. W., … Wilson, M. S. (2016). Position paper for guiding response to non-​suicidal self-​injury in schools. School Psychology International, 37(6), 644–​663. Hasking, P., Whitlock, J., Voon, D., & Rose, A. (2017). A cognitive-​emotional model of NSSI: Using emotion regulation and cognitive processes to explain why people self-​ injure. Cognition and Emotion, 31(8), 1543–​1556. Heath, N. L., Ross, S., Toste, J. R., Charlebois, A., & Nedecheva, T. (2009). Retrospective analysis of social factors and nonsuicidal self-​injury among young adults. Canadian Journal of Behavioural Science, 41(3), 180–​186. doi:10.1037/​a0015732 Heath, N. L., Toste, J. R., & MacPhee, S. D. (2010). Prevention of nonsuicidal self-​injury. In The Oxford handbook of suicide and self-​injury (pp. 397–​408). New  York:  Oxford University Press. Hedman, E., Ljótsson, B., & Lindefors, N. (2012). Cognitive behavior therapy via the Internet: A systematic review of applications, clinical efficacy and cost–​effectiveness. Expert Review of Pharmacoeconomics & Outcomes Research, 12(6), 745–​764. Hoagwood, K. E., Cavaleri, M. A., Olin, S. S., Burns, B. J., Slaton, E., Gruttadaro, D., & Hughes, R. (2010). Family support in children’s mental health: A review and synthesis. Clinical Child and Family Psychology Review, 13(1), 1–​45.

236  Kaylee P. Kruzan and Janis Whitlock Isava, D.  M. (2006). An investigation on the impact of a social emotional learning curriculum on problem symptoms and knowledge gains among adolescents in a residential treatment center (Doctoral dissertation, University of Oregon). Jacobs, D., Walsh, B. W., McDade, M., & Pigeon, S. (2009). Signs of self-​injury prevention manual. Wellesley Hills, MA: Screening for Mental Health. Jacobson, C. M., & Gould, M. (2007). The epidemiology and phenomenology of non-​ suicidal self-​injurious behavior among adolescents: A critical review of the literature. Archives of Suicide Research, 11(2), 129–​147. Jantzer, V., Haffner, J., Parzer, P., Resch, F., & Kaess, M. (2015). Does parental monitoring  moderate the relationship between bullying and adolescent nonsuicidal self-​injury and suicidal behavior? A community-​based self-​report study of adolescents in Germany. BMC Public Health, 15(1), 583. Jarvi, S., Jackson, B., Swenson, L., & Crawford, H. (2013). The impact of social contagion on non-​suicidal self-​injury: A review of the literature. Archives of Suicide Research, 17(1),  1–​19. Jason, L. A., & Rhodes, J. E. (1989). Children helping children: Implications for prevention. The Journal of Primary Prevention, 9(4), 203–​212. Kass, A.  E., Trockel, M., Safer, D.  L., Sinton, M.  M., Cunning, D., Rizk, M.  T., … Wilfley, D. E. (2014). Internet-​based preventive intervention for reducing eating disorder risk: A randomized controlled trial comparing guided with unguided self-​help. Behavior Research and Therapy, 63, 90–​98. Kawachi, I. & Berkman, L. F. (2000). Social cohesion, social capital, and health. In L. F. Berkman & I. Kawachi (Eds.). Social epidemiology (pp. 174–​190). New York: Oxford University Press. Klingman, A. & Hochdorf, Z. (1993). Coping with distress and self harm: The impact of a primary prevention program among adolescents. Journal of Adolescence, 16(2), 121–​140. Kramer,T. J., Caldarella, P., Christensen, L., & Shatzer, R. H. (2010). Social and emotional learning in the kindergarten classroom:  Evaluation of the Strong Start curriculum. Early Childhood Education Journal, 37(4), 303. Levin, M.  E., Hayes, S.  C., Pistorello, J., & Seeley, J.  R. (2016). Web-​based self-​help for preventing mental health problems in universities:  Comparing acceptance and commitment training to mental health education. Journal of Clinical Psychology, 72(3), 207–​225. Levin, M. E., Pistorello, J., Hayes, S. C., Seeley, J. R., & Levin, C. (2015). Feasibility of an Acceptance and Commitment Therapy adjunctive web-​based program for counseling centers. Journal of Counseling Psychology, 62(3), 529–​ 536. doi:10.1037/​ cou0000083 Lindenberg, K., & Kordy, H. (2015). Wirksamkeit eines gestuften, Internetvermittelten Ansatzes zur Prävention von Essstörungen bei Schülern der 7. bis 10. Klasse. [Efficacy of an internet-​delivered tiered strategy for eating disorder prevention in high school students]. Kindheit und Entwicklung:  Zeitschrift für Klinische Kinderpsychologie, 24(1), 55–​63. doi:10.1026/​0942-​5403/​a000152. Linehan, M. M. (1993). Cognitive behavioral therapy of borderline personality disorder (Vol. 51). New York: Guilford Press. LoMurray, M. (2005). Sources of strength facilitators guide: Suicide prevention peer gatekeeper training. Bismarck, ND: The North Dakota Suicide Prevention Project.

Prevention of Nonsuicidal Self-Injury  237 Marchant, M., Brown, M., Caldarella, P., & Young, E. (2010). Effects of Strong Kids curriculum on students with internalizing behaviors:  A pilot study. Journal of Evidence-​ Based Practices for Schools, 11(2), 123–​143. Mayo-​ Wilson, E., & Montgomery, P. (2013). Media-​ delivered cognitive behavioral therapy and behavioral therapy (self-​help) for anxiety disorders in adults. The Cochrane Database of Systematic Reviews, 9(9), CD005330. doi:10.1002/​14651858. CD005330.pub4. Mazza, J. J. & Dexter-​Mazza, E. T. (2017). DBT skills in schools: Implementation of the DBT STEPS-​A social emotional curriculum. In M. A. Swales (Ed.). The Oxford handbook of dialectical behavior therapy (pp. 1–​19). Oxford: Oxford University Press. Mazza, J. J., Dexter-​Mazza, E. T., Miller, A. L., Rathus, J. H., & Murphy, H. E. (2016). DBT® skills in schools:  Skills training for emotional problem solving for adolescents DBT STEPS-​A. New York: Guilford. Mazza, J. J., & Hanson, J. B. (2015, February). Implementing DBT Emotion Regulation Skills for Tier II–​III Students. Invited workshop presented at the national conference of the National Association of School Psychologists. Orlando, FL. Merrell, K.  W. (2010). Linking prevention science and social and emotional learning: The Oregon Resiliency Project. Psychology in the Schools, 47(1), 55–​70. Merrell, K. W., Juskelis, M. P., Tran, O. K., & Buchanan, R. (2008). Social and emotional learning in the classroom:  Evaluation of strong kids and strong teens on students’ social-​emotional knowledge and symptoms. Journal of Applied School Psychology, 24(2), 209–​224. Merry, S. N., Hetrick, S. E., Cox, G. R., Brudevold-​Iversen, T., Bir, J. J., & McDowell, H. (2011). Psychological and educational interventions for preventing depression in children and adolescents. Cochrane Database of Systematic Reviews, CD003380. http://​ dx.doi.org/​10.1002/​14651858.CD003380.pub3. Metz, S. M., Frank, J. L., Reibel, D., Cantrell, T., Sanders, R., & Broderick, P. C. (2013). The effectiveness of the Learning to BREATHE program on adolescent emotion regulation. Research in Human Development, 10(3), 252–​ 272. doi:10.1080/​ 15427609.2013.818488 Morris, A. S., Silk, J. S., Steinberg, L., Myers, S. S., & Robinson, L. R. (2007). The role of the family context in the development of emotion regulation. Social Development, 16, 361–​388. Muehlenkamp, J.  J. (2012). Body regard in nonsuicidal self-​ injury:  Theoretical explanations and treatment directions. Journal of Cognitive Psychotherapy, 26(4), 331–​347. doi:10.1891/​0889-​8391.26.4.331 Muehlenkamp, J. J., & Brausch, A. M. (2012). Body image as a mediator of non-​suicidal self-​injury in adolescents. Journal of Adolescence, 35(1), 1–​9. Muehlenkamp, J.  J., Brausch, A., Quigley, K., & Whitlock, J. (2013). Interpersonal features and functions of nonsuicidal self-​injury. Suicide and Life-​Threatening Behavior, 43(1),  67–​80. Muehlenkamp, J. J., Walsh, B., & McDale, M. (2010). Preventing non-​suicidal self-​injury in adolescents: The signs of self-​injury program. Journal of Youth and Adolescence, 39(3), 306–​314. doi:10.1007/​s10964-​009-​9450-​8 Muñoz, R.  F., Cuijpers, P., Smit, F., Barrera, A.  Z., & Leykin, Y. (2010). Prevention of major depression. Annual Review of Clinical Psychology, 6, 181–​212. http://​dx.doi.org/​ 10.1146/​annurev-​clinpsy-​033109-​132040

238  Kaylee P. Kruzan and Janis Whitlock Nelson, A., & Muehlenkamp, J.  J. (2012). Body attitudes and objectification in non-​ suicidal self-​ injury:  Comparing males and females. Archives of Suicide Research, 16(1),  1–​12. Noble, R., Sornberger, M., Toste, J., Heath, N., & McLouth, R. (2011). Safety first: The role of trust and school safety in non-​suicidal self-​injury. McGill Journal of Education/​ Revue des sciences de l’éducation de McGill, 46(3), 423–​441. Nock, M. K. (2009). Why do people hurt themselves? New insights into the nature and functions of self-​injury. Current Directions in Psychological Science, 18(2), 78–​83. Nock, M., & Favazza, A. R. (2009) Non-​suicidal self-​injury: Definition and classification. In: M. Nock (Ed.). Understanding non-​suicidal self-​injury: Origins, assessment, and treatment. Washington, DC: American Psychological Association. Nock, M. K., & Mendes, W. B. (2008). Physiological arousal, distress tolerance, and social problem-​ solving deficits among adolescent self-​ injurers. Journal of Consulting and Clinical Psychology, 76(1), 28. Oldershaw, A., Richards, C., Simic, M., & Schmidt, U. (2008). Parents’ perspectives on adolescent selfharm: Qualitative study. The British Journal of Psychiatry, 193, 140–​144. Prinstein, M.  J., Heilbron, N., Guerry, J.  D., Franklin, J.  C., Rancourt, D., Simon, V., & Spirito, A. (2010). Peer influence and nonsuicidal self injury: Longitudinal results in community and clinically-​referred adolescent samples. Journal of Abnormal Child Psychology, 38(5), 669–​682. Sander, L., Rausch, L., & Baumeister, H. (2016). Effectiveness of internet-​ based interventions for the prevention of mental disorders: A systematic review and meta-​ analysis. JMIR Mental Health, 3(3). Stallard, P., Skryabina, E., Taylor, G., Phillips, R., Daniels, H., Anderson, R., & Simpson, N. (2014). Classroom-​ based cognitive behavior therapy (FRIENDS):  A cluster randomised controlled trial to Prevent Anxiety in Children through Education in Schools (PACES). The Lancet Psychiatry, 1, 185–​ 192. http://​dx.doi.org/​10.1016/​ S2215-​0366(14)70244–​5. Sim, L., Adrian, M., Zeman, J., Cassano, M., & Friedrich, W. N. (2009). Adolescent deliberate selfharm: Linkages to emotion regulation and family emotional climate. Journal of Research on Adolescence, 19, 75–​91. Tatnell, R., Kelada, L., Hasking, P., & Martin, G. (2014). Longitudinal analysis of adolescent NSSI: The role of intrapersonal and interpersonal factors. Journal of Abnormal Child Psychology, 42(6), 885–​896. Taylor, C. B., Kass, A. E., Trockel, M., Cunning, D., Weisman, H., Bailey, J., … Wilfley, D. E. (2016). Reducing eating disorder onset in a very high risk sample with significant comorbid depression: A randomized controlled trial. Journal of Consulting and Clinical Psychology, 84(5), 402. Thompson, N. J., Patel, A. H., Selwa, L. M., Stoll, S. C., Begley, C. E., Johnson, E. K., & Fraser, R. T. (2015). Expanding the efficacy of Project UPLIFT: Distance delivery of mindfulness-​based depression prevention to people with epilepsy. Journal of Consulting and Clinical Psychology, 83(2), 304. Van der Zanden, R., & van der Linden, D. (2013). Evaluatieonderzoek Happyles Den Haag. Implementatie van Happyles in het VMBO en de Jeugdzorgketen ter bevordering van de mentale veerkracht van jongeren. Utrecht: Trimbos-​instituut. Van Vliet, K., & Kalnins, G. (2011). A compassion-​focused approach to nonsuicidal self-​ injury. Journal of Mental Health Counseling, 33(4), 295–​311.

Prevention of Nonsuicidal Self-Injury  239 Walther, J.  B., & Boyd, S. (2002). Attraction to computer-​mediated social support. In C.  A.  Lin & D. Atkin (Eds.), Communication technology and society:  Audience adoption and uses (pp. 153–​188). Cresskill, NJ: Hampton Press. Wedig, M. M., & Nock, M. K. (2007). Parental expressed emotion and adolescent self-​ injury. Journal of the American Academy of Child & Adolescent Psychiatry, 46, 1171–​1178. Werner-​Seidler, A., Perry, Y., Calear, A.  L., Newby, J.  M., & Christensen, H. (2017). School-​based depression and anxiety prevention programs for young people: A systematic review and meta-​analysis. Clinical psychology review, 51, 30–​47. Whitlock, J., & Knox, K. L. (2009). Intervention and prevention in the community. In M. K. Nixon & N. L. Heath (Eds.), Self-​injury in youth: The essential guide to assessment and intervention (pp. 173–​194). New York, NY: Routledge. Whitlock, J., Prussien, K., & Pietrusza, C. (2015). Predictors of NSSI recovery and growth in young adults. Child and Adolescent Psychiatry and Mental Health, 9, 19. doi:10.1186/​ s13034-​015-​0048-​5 Whitlock, J. L., Purington, A., & Gershkovich, M. (2009). Influence of the media on self-​ injurious behavior. In M. Nock (Ed.), Understanding non-​suicidal self-​injury: Current science and practice (pp. 139–​156). Washington, DC: American Psychological Association Press. Whitlock, J. L. & Selekman, M. (2014). Non-​suicidal self-​injury (NSSI) across the lifespan. In M. Nock (Ed.). Oxford handbook of suicide and self-​injury. Oxford:  Oxford University Press. Wyman, P. A., Brown, C. H., LoMurray, M., Schmeelk-​Cone, K., Petrova, M.,Yu, Q., … Wang,W. (2010). An outcome evaluation of the Sources of Strength suicide prevention program delivered by adolescent peer leaders in high schools. American Journal of Public Health, 100(9), 1653–​1661. Xavier, A., Gouveia, J. P., & Cunha, M. (2016, August). Non-​suicidal self-​injury in adolescence: The role of shame, self-​criticism and fear of self-​compassion. Child & Youth Care Forum, 45(4), 571–​586.

Index

Note: Page numbers in bold refer to tables and in italics to figures. ABASI (Alexian Brothers Assessment of Self-​Injury)  141 ABUSI (Alexian Brothers Urge to Self-​Injure)  141 ACC (anterior cingulate cortex) 47, 60, 62, 97 acceptance and commitment therapy see ACT acceptance 143, 149–​150, 159, 197, 199, 208 acculturation 25 ACEs (adverse childhood experiences) 23–​24, 30, 66; see also children; emotional abuse; physical abuse; sexual abuse acetaminophen (Tylenol) 47 ACT (acceptance and commitment therapy) 96, 149, 154 adolescents: adverse childhood experiences (ACEs) and 23; affective instability 60; anticipated rewards 60; assessment instruments 138; body image 222; bullying 223; clinical severity of NSSI 21; dialectical behaviour therapy (DBT) 96, 170; environmental factors 23; establishment of rapport 144; impulsivity 99; interpersonal sensitivity 22; obsessive compulsive disorder (OCD) 89; online community 205; pain and 43, 44, 45, 49, 51, 61–​62, 64; predictors for NSSI 29, 30; prevalence of NSSI in 6, 7, 71, 74–​79; prevention in 217–​218, 222–​229; risk factors 135; social contagion and 9, 224; social triggers 222; stress 63, 64–​66; suicidality 26, 110, 111–​113,

114, 117; see also ERITA (emotion regulation individual therapy for adolescents); schools adrenal glands 63 adverse childhood experiences see ACEs affect regulation 8–​9, 46, 48, 60, 88, 90, 93, 132; models of 20 age of onset of NSSI 6, 79, 114, 164, 183 alcohol use 21, 22, 24, 29 Alexian Brothers Assessment of Self-​ Injury see ABASI Alexian Brothers Urge to Self-​Injure see ABUSI American Psychiatric Association see APA Ammerman, B. A. et al. (2016) 43 Ammerman, B. A. et al. (2017) 74 Ammerman, B. A. et al. (2018) 164 amygdala 59, 60, 62, 97 analgesia 42, 61 Andover, M. S. 74 anterior cingulate cortex see ACC anterior insula 42, 47 anterior precuneus 62 anti-​dissociation function  8 anti-​suicide function  8, 110 anxiety: characteristics of NSSI and 29, 31; compassion training and 229; diagnostic criteria and 79–​80; and obsessive compulsive disorder (OCD) 89, 90; obsessive-​compulsive and related disorders (OCRDs) 90, 91, 92, 93, 94; race and ethnicity and 25; and suicidality 26, 118; symptoms of 25, 31 anxiety disorders 89, 135, 159, 232 APA (American Psychiatric Association) 82

Index 241 APD (avoidant personality disorder) 31 apps (mobile applications) 8, 52, 143, 205, 232 Arbuthnott, A. E. et al. (2015) 20 Arnold, L. M. et al. (2001) 99 Asian students, prevalence of NSSI in 25 assessment 127–​144; assessment frameworks 137–​138; assessment instruments 138–​142; demeanor and rapport 143–​144; determination of severity 129–​132; history and severity 128; initial screening 127–​128; privacy and 144 attention-​deficit/​hyperactivity disorder  11 atypical, severe NSSI 164–​173; functions of 167–​169; hierarchy of risk for 169–​170, 172; studies of 166–​167; suicidal ideation and 167; treatment of 169–​172 automatic functions 8, 9 autonomic arousal 62 avoidance 91, 96, 99, 149–​152, 219, 226 avoidant personality disorder see APD awareness training 95 Baetens, I. et al. (2014) 226 Baiden, P. et al. (2017) 223 Barrocas, A. L. et al. (2015) 28 Bastian, B. et al. (2014) 45 BDD (body dysmorphic disorder) 91–​92, 93, 95, 97 behavioral neurodevelopmental disorders 11 Berenson, K. R. 51 BFRBs (body-​focused repetitive behaviors) 91, 95, 98 binge behavior 20, 22, 75 BIP (barninternetprojektet) (Child Internet Project) 159–​160 body disregard 221–​222 body dysmorphic disorder see BDD body-​focused repetitive behaviors see BFRBs body image and regard 92, 221–​222 body objectification 222 Borderline Evaluation of Severity over Time scale 10 BPD (borderline personality disorder): and emotional dysregulation 20; emotional regulation group therapy (ERGT) and 148–​149, 151–​156; neurobiology of 59, 60; and NSSI 9,

10, 11, 29, 31, 48, 71–​72, 82, 83, 135; and obsessive compulsive disorder (OCD) symptoms 89; and pain tolerance 44, 61, 62; and social stress 64–​65; symptoms 11; and suicidality 110–​111, 118 Bracken-​Minor, K. L. et al. (2012) 28 Brausch, A. M. 74 breast self-​injury 131, 138, 165–​166 The Bridge, Massachusetts 166–​172 Brown, R. C. et al. (2018) 197 bulimia nervosa 75 bullying victimization 22, 64, 66, 187, 223, 226 Burke, T. A. et al. (2017) 80 Buser, J. K. 137 Buser, T. J. 137, 164 Canada, confidentiality 184–​185 carving 30 Casey, L. 198 catechol-​O-​methyl transferase see COMT CBT (cognitive behavioral therapy) 95–​96, 97, 171, 226 CEMNSSI (Cognitive-​Emotional Model for NSSI) 25, 219–​220, 221 cerebrospinal fluid 61 chain analysis 142 Child Internet Project see BIP (barninternetprojektet) children: DSM-​5 and 72; elementary school 183; maltreatment as risk factor 11, 23, 24, 30, 135, 141, 167, 171, 172, 177, 220; onset in 138; paternal role 23; see also ACEs (adverse childhood experiences); adolescents clinical severity 21–​22, 29, 32, 80, 132, 141 Clinician-​Administered Nonsuicidal Self-​Injury Disorder Index 82 clomipramine see SRI Cluster B personality disorder 61 cognitive behavioral therapy see CBT cognitive behavioral tracking methods 142–​143 Cognitive-​Emotional Model for NSSI see CEMNSSI cognitive restructuring see CR cold pressor test 62 comorbidity 10–​12, 19–​22, 88–​91, 100, 135–​136 compassion training 228–​229

242 Index competing response training 95 compulsive disorders 88–​101; body dysmorphic disorder (BDD) 91–​92; compulsive subtypes of NSSI 94, 98–​100; hording disorder 93; impulsive subtypes of NSSI 98–​100; obsessive compulsive disorder (OCD) 88–​90; obsessive-​compulsive related disorders (OCRDs) 90–​99; skin-​picking disorder (SPD) 93–​95; trichotillomania (TTM) 92–​93 COMT (catechol-​O-​methyl transferase) 44 confidentiality 144, 176, 177, 178–​179, 184, 185, 188 contextual factors 132–​134 co-​occurrence see comorbidity coping strategies 136; alcohol use 29; alternative 134, 137, 180; NSSI as 66, 78, 143, 220, 222; online activity and 199–​200, 202, 210; prevention programs and 228 Cornell Research Program on Self-​Injury and Recovery 201 cortisol secretion 62, 63–​64, 97 CR (cognitive restructuring) 95, 96, 170–​172 criminal behaviors 24 Croyle, K. L. 99 cultural factors 25, 183–​184, 189, 190 “cutters” as term 4, 5 cutting behavior 5–​6; and atypical, severe NSSI 172; case studies 184–​185, 188–​189, 210; conditioning methods and 52; and gender 30; location 131; suicidality and 29, 72, 117; tissue damage and 130 cyber-​bullying  203 dACC see dorsal anterior cingulate cortex Dahlstrom, O. 9 DBT (dialectical behavior therapy) 62, 96, 142, 149, 154, 170, 172 DBT Skill Training for Emotional Problem Solving for Adolescents (DBT STEPS-​A) 227–​228, 230 DC (decoupling) 96–​97 death, fear of 115–​116 deliberate self-​harm as term 4 Deliberate Self-​Harm Inventory see DSHI deliberate self-​injury as term 4 depression: cognitive restructuring (CR) and 171, 172; Emotion Regulation

Group Therapy (ERGT) and 152; major depressive disorder 10, 21, 90; programs for 226, 229; and social stress 64; and suicidality 26, 112, 117–​118; tech-​based prevention 232; and variability in NSSI 28, 29 dexamethasone suppression test 63–​64 diagnostic classification 71–​84; DSM-​5 criteria and 71–​80 dialectical behavior therapy see DBT disinhibition 11 dissociation 19, 31, 141, 222 distress, marking of 8, 9, 75 distress tolerance 11, 220–​221 Doerfler, L. A. 166–​167 dopamine 44, 97 dorsal anterior cingulate cortex (dACC) 42 dorsal striatum 62 dorsolateral prefrontal cortex 60, 62 Dougherty, D. M. et al. (2009) 117 drug withdrawal 77 DSHI (Deliberate Self-​Harm Inventory) 140 DSM-​IV  24 DSM-​5 (Diagnostic and Statistical Manual of Mental Disorders) 71–​84; borderline personality disorder (BPD) 135; Childhood Disorder and Mood Disorder Work Groups 72; criteria for NSSI 65, 73–​81; NSSI and suicidality 109; obsessive-​compulsive and related disorders (OCRDs) 90 eating disorders (ED) 11, 19, 20, 135, 171, 222, 232 Ebert, D. D. et al. (2017) 232 ecological momentary assessment see EMA ED see eating disorders EDB (eating disorder behaviors) 20, 22 electric shock 52 EMA (ecological momentary assessment) 8, 30–​31, 60, 143, 205 emotion regulation 20; and body dysmorphic disorder (BPD) 10; cultural factors 183; and dialectical behaviour therapy (DBT) 96; distraction model 46; method and 31; neurobiology of 59–​62, 97; NSSI disorder (NSSID) criteria for 78; and pain 60–​62; prevention and 216, 228; as risk factor 219–​220; role of parents 224; and

Index 243 skin-​picking disorder (SPD) 94; and suicidality 26; see also ERGT (Emotion Regulation Group Therapy); ERITA (emotion regulation individual therapy for adolescents) Emotion Regulation Group Therapy see ERGT emotion regulation individual therapy for adolescents see ERITA emotional abuse 25, 113 emotional disorders 11, 19 emotional reactivity 12, 20, 22, 46, 80, 150, 220 ERGT (Emotion Regulation Group Therapy) 148–​160; adaptation for adolescents 156–​160; Dissemination Project, Sweden 153–​156; modules 150; women with body dysmorphic disorder (BPD) 151–​156 ERITA (emotion regulation individual therapy for adolescents) 156–​160 escalation 9, 130, 143, 187 ethnic minority students 25 Excoriation Disorder see SPD (skin-​picking disorder) expectancies 42, 157, 160, 221, 226 experiential avoidance 96, 152, 219 Facebook 203, 210–​211 facial self-​injury 131, 136, 164, 165 family environment 177 FASM (Functional Assessment of Self-​Mutilative Behavior)  139 fasting 20, 22 Favazza, A. R. 72, 99, 127 FBI (foreign body ingestion) 164, 166, 168–​169, 171, 172 fire-​setting  21, 22 First Swedish National Conference on Self-​Harm, Stockholm  154 fMRI (functional magnetic resonance imaging) 59, 62, 66 foreign body ingestion see FBI four-​function model of NSSI 8, 9, 167–​169 Fox, K. R. et al. (2017) 46, 47, 49 Franklin, J. C. et al. (2011) 115 Franklin, J. C. et al. (2013b) 52 Franklin, J. C. et al. (2016) 52 frequency of NSSI 5, 6, 7; assessment of 128, 129, 137, 138, 139–​141; and body dysmorphic disorder (BDD) 93; and borderline personality disorder (BPD)

10; cultural norms and 25; Emotion Regulation Group Therapy (ERGT) and 152, 153; emotion regulation individual therapy for adolescents (ERITA) and 157, 159; and function of NSSI 9; healing and 130; intrapersonal functions of NSSI and 30; methods and 6; NSSI disorder (NSSID) diagnostic criteria 74–​75, 76, 79, 80, 81; pain and 44, 45; skin-​picking disorder (SPD) 91; social contagion and 180; and suicidality 26, 31, 114, 115, 116–​117; and variability 28 Frost, M. 198 Functional Assessment of Self-​Mutilative Behavior see FASM functional magnetic resonance imaging see fMRI GAF scores (Global Assessment of Functioning) 78 gateway theory 114, 117 gender: borderline personality disorder (BPD) and 24, 148, 149, 151–​153, 155–​156; compulsive and impulsive subtypes of NSSI and 99; Emotion Regulation Group Therapy (ERGT) 148, 149, 151–​153, 155–​156; emotion regulation individual therapy for adolescents (ERITA) 157; intrapersonal functions and 30; methods and 30; and pain perception 44; and prevalence 7, 187; as risk factor 135; stigma and 187, 188; and suicidality 118–​119; variability of NSSI and 28 gene–​environment interactions  64 generalized anxiety disorder 135 genital self-​injury 131, 138, 164, 165–​166, 168 Gholamrezaei, M. 183 Glazer, J. V.  51 Glenn, C. R. 135 Global Assessment of Functioning see GAF glutamatergic agents 97 Gratz, K. L. 148, 149 Gratz, K. L. et al. (2015) 79 Gregory, W.  E.  51 Groschwitz, R. C. et al. (2015) 111 Grossman, R. 165 habit reversal training see HRT hair-​pulling see TTM (trichotillomania)

244 Index Hamza, C. A. 26, 27 HAPPYLES program 226, 230 HAPPYLES+ program 226, 229, 230 HD (hoarding disorder) 93 heat-​induced pain  61, 62 Heath, N. L. 183 Heath, N. L. et al. (2009) 134 Heath, N. L. et al. (2010) 218 Heim, C. et al. (2000) 63 help-​seeking and giving, and internet 197–​198 heterogeneity 23–​32 HIRE model of assessment (history, interest, reasons, exposure) 137 Hispanic students 25 hoarding disorder see HD Hom, M. A. et al. (2017) 167 homeostasis model of NSSI 61 Hong Kong, cultural considerations 183 Hooley, J. M. 50, 51 Hooley, J. M. et al. (2010) 43, 48 hopelessness 19, 29, 117, 221 HPA (hypothalamic–​pituitary–​adrenal) axis 63–​64 HRT (habit reversal training) 95–​97 hypalgesia 61 hyperactivity disorder see attention-​ deficit/​hyperactivity disorder hypothalamic–​pituitary–​adrenal axis see HPA axis

internet: Emotion Regulation Group Therapy (ERGT) 155, 157; emotion regulation individual therapy for adolescents (ERITA) 159–​160; information 197; internet-​based CBT (ICBT) 159; online NSSI activity 134–​135, 195–​211; and prevention 218, 229, 232; and social contagion 224 internet-​based CBT see ICBT interpersonal (social) functions of NSSI 8, 9, 88, 132; adverse life events (ACEs) 23, 24; and atypical, severe NSSI 167–​169; consequences of 134; cultural factors and 183; diagnostic criteria 73, 75, 76, 77, 80; peers 222–​223; as predictors 29–​30; and prevention 224; and social stress 64 interpersonal effectiveness 170 Interpersonal–Psychological Theory of Suicidal Behavior 21, 114–​115 interpersonal sensitivity 22–​23, 32 intersectionality 25 intrapersonal (internal) functions 8, 23, 24, 29–​30, 60, 88, 132, 167–​168 Iran, cultural factors 183 ISAS (Inventory of Statements About Self-​ Injury) 139–​140 isolation, social 27, 31, 187, 198–​199 ISSS (International Society for the Study of Self-​Injury)  3

ICBT (internet-​based CBT) 159 ideation-​to-​action theories of suicide 21 illness, management and recovery model see IMR impulsive behaviors 19, 26, 28, 117–​118, 133, 135, 149 impulsive subtypes of NSSI 98–​100 IMR (illness, management and recovery) model 171, 172 India, cultural factors 183 indirect self-​harm behaviors 21, 26–​27, 51, 140, 141 Instagram 197 institutionalization 172 internal functions see intrapersonal functions International Affective Picture System 62 International Classification of Diseases (World Health Organization) 71 International Society for the Study of Self-​Injury see ISSS

Joiner, T. E., Interpersonal–​Psychological Theory of Suicidal Behavior 21, 114–​116 Kaess, M. et al. (2012) 64 Karolinska Institutet 159 Kelada, L. et al. (2016) 177 Kerr, P. L. 138 Kessel, N. 4 Kleiman, E. M. et al. (2015) 30 Klonsky, E. D. 118, 132, 135 Knox, K. L. 217, 222 Kreitman, N. et al. (1969) 4 latent class analyses 26, 29 Law, B. M. F. 28 Learning to Breathe program 228, 229, 231 Lenzenweger, M. F. 44 Lewis, S. P. 197, 198, 204 Lewis, S. P. et al. (2012c) 199

Index 245 Lewis, S. P. et al. (2014) 200 limbic system, hyperarousal of 97 Lin, M.-​P.  113 location of injury 131, 136, 138, 164, 165–​166, 168 Ludascher, P. et al. (2009) 61 Lundh, L.-​G.  9 major depressive disorder 10, 21, 90 Making Friends with Yourself: A Mindful Self-​Compassion Program for Teens see MFY Mandrusiak, M. N. 203 meaning-​making  27 medical treatment, necessity for: compulsive NSSI and 98, 99, 100; and method 6, 110–​111, 130; and parental awareness 178; and severity 130–​131, 138, 139, 140, 164, 165, 168–​169; and suicidality 110–​111 Mendes, W.  B.  63 Menninger, K. 4, 109 methods of NSSI 5–​6; assessment of 129–​130; and suicide attempt 116–​117 MFY (Making Friends with Yourself: A Mindful Self-Compassion Program for Teens) 228–​229, 231 MI (motivational interviewing) 209, 211 Michal, N. J. 197, 198 mindfulness 96, 170, 220, 227, 228–​229, 231 Mitchell, K. J. et al. (2014) 203 monitoring: body dysmorphic disorder (BDD) as 92; Emotion Regulation Group Therapy (ERGT) and 151, 155; obsessive-​compulsive and related disorders (OCRDs) 96; of online activity 206; and privacy 144; school mental health professionals (SMHPs) and 176, 188; tracking and 142–​143 mood disorders 10, 19 mood regulation 45–​51 Morgan, H. G. et al. (1975) 4 motivation to change, assessment of 136, 137 motivational interviewing see MI Muehlenkamp, J. J. 72, 74, 138, 221–​222 Muehlenkamp, J. J. et al. (2010) 226 Muehlenkamp, J. J. et al. (2012) 7 nail-​biting 73, 95, 97 natural environment 183

negative cognition 221, 230 negative feedback loops 22, 63 negative urgency 11, 135 neurobiology 59–​66, 97–​98 neurochemistry 97–​98 neuroticism 135 Niedtfeld, I. et al. (2010) 62 Niwa, K. D. 203 nocioception 45 Nock, M. K. 8, 61, 63, 127, 167–​169 Nock, M. K. et al. (2006) 43 non-​Hispanic white students 24–​25 nonconformist peer identification 9 Nonsuicidal Self-​Injury Disorder Scale see NSSIDS NSSI (nonsuicidal self-​injury): definition 3–​4, 127; as distinct condition 10–​12; epidemiology 6–​7; functions of 8–​10; further research areas 12; initial screening for 127; methods 5–​6, 116–​117, 129–​30 NSSID (NSSI disorder) 71–​84; DSM-​5 and 71–​82; importance of 82–​84 NSSIDS (Nonsuicidal Self-​Injury Disorder Scale) 82 OCD (obsessive compulsive disorder) 88–​90, 93, 95, 97 OCRDs (obsessive-​compulsive and related disorders) 90–​91, 93, 95–​98, 100 ocular self-​injury 131, 164, 165, 168 online self-​injury activity 195–​211; anonymity and 197; assessment of 206–​208; case study 209–​211; disclosure 199; intervention and 208–​209; motives for 196–​198; potential benefits of 198–​200; potential risks of 201–​203; recommendations for clinicians 205; recovery encouragement and 200; and resource provision 200–​201; as safe space 197, 199, 200; schools and 180 openness 135 opioid antagonists 98 opioids 9, 50, 61, 63, 97 OPRM1 (μ-​opioid receptor gene) 44 orbitofrontal cortex 62 ORI (Oregon Resiliency Initiative) 228 OSI (Ottawa Self-​Injury Inventory) 141–​142 Owens, C. et al. (2012) 199

246 Index pain 41–​53; affective component 41–​42; distraction model of 45–​46; elevated threshold of 61–​62; and emotional regulation 60–​62; habituation to 21, 115; heat-​induced 61, 62; localization of 41, 42; and mood regulation 45, 47–​48, 49; and NSSI 42–​44; perception of 41–​45; processing 43–​44; and self-​criticism 48–​50; sensitivity and suicidality 115; sensory component of 41–​42; tolerance 42–​43, 61 Panaghi, L. 183 parasuicide as term 4 parents: engagement of 176–​179; role in prevention 224–​225 Pavony, M. T. 44 peer-​mentors  182 peers 9, 19, 23, 28, 30, 134, 199, 222–​229 perigenual anterior cingulate cortex 62 Perry, A. 168 personality disorders 24 physical abuse 24, 25, 118, 167, 171 physiological hyperarousal 63 Plener, P. L. et al. (2012) 62 Ploner, M. et al. (2017) 42 poisoning 5 positive reinforcement 30, 98, 99, 100 post-​traumatic stress disorder see PTSD posterior cingulate cortex 60 posterior insula 42 posterior parietal cortex 62 prevalence of NSSI 6–​7, 24–​25, 73–​75, 82–​83, 111 prevention 215–​232; ecological approaches 217; pedagogy 218–​219; prevention level and target 216–​217; programs 230–​231; risk and protective factors 219–​224; role of parents 224–​225; and social contagion 223–​224; timing and 217–​218; venue 218 Prinstein, M. J. 8, 61, 167–​169 protective factors 27, 177, 183, 184, 216, 219–​223, 227 psychic distress 21 psychoanalysis 4 psychoeducation 95, 96, 149, 157, 171, 225, 226, 228 psychogenic excoriation see SPD (skin-​ picking disorder) psychopathology: atypical, severe NSSI and 167; bullying victimization and

223; emotion dysregulation and 20; NSSI and 10, 23, 66, 73, 74, 78, 79–​80, 81; skin-​picking disorder (SPD) and 94; and suicidality 117 psychosis 19, 165, 171 psychotropic medication 21 PTSD (post-​traumatic stress disorder) 19, 63, 117, 118, 135, 165–​166, 170–​171, 172 purge behaviour 20, 22, 75 race and ethnicity 24–​25 rejection 31, 199, 223 reinforcement: acceptance and 143; and atypical, severe NSSI 168–​169; compulsive disorders and 88–​91, 95, 98–​99; consequences and 133; early life trauma and 30, 66; escalation and 130; impulsive disorders and 99; negative 9, 30, 88, 91; online NSSI activity and 144, 180, 201–​202; pain and 47, 50, 52, 62; short-​term 136; relaxation training and 95 religious belief 184 resilience 78, 137, 183, 221, 227, 228 rewards, anticipated 66 risk factors for NSSI 22, 25, 135–​136, 219–​224; atypical, severe NSSI 169–​170, 172 Roemer, L. 149 Rosenthal, R. J. 72 S.A.F.E. see Self Abuse Finally Ends Santa Mina, D. et al. (2006) 141 SASII (Suicide Attempt Self-​Injury Interview) 139 school mental health professionals see SMHPs schools 175–​190; bullying victimization 223; case studies 184–​190; cultural factors 183–​184; diverse school environments 182–​183; elementary schools 183; parents and guardians 176–​179, 224–​225; prevention and 216–​218; school mental health professionals (SMHPs) 175–​176, 178–​179; and social contagion 179–​182, 224; suicide risk 176; and triggering 180–​181 scratching 5, 6, 30, 130 Seko, Y. 204 Selby, E. A. et al. (2015) 82 selective serotonin reuptake inhibitors see SSRIs

Index 247 Self Abuse Finally Ends (S.A.F.E.) 201 self-​criticism 12, 21–​22, 24, 48–​50, 52 self-​efficacy  221 Self-​Harm Behavior Questionnaire see SHBQ Self-​Harm Inventory see SHI self-​hatred 22, 50, 51 self-​hitting  29, 30 self-​image  24 Self-​Injurious Thoughts and Behaviors Interview see SITBI Self-​Injury Outreach and Support (SiOS) 210 Self-​Injury Questionnaire see SIQ Self-​Injury Tracking Logs 142–​143 self-​punishment 8, 48–​49, 50, 75 self-​compassion 51–​52, 220, 228–​229 self-​schemas 50, 51, 221 self-​worth 50, 51, 52, 53, 219 serotonin abnormalities 97 severity 21–​22, 32, 128–​132; atypical, severe 164–​173; borderline personality disorder (BPD) and 10; characteristics and 29; and chronic NSSI 9; cultural factors and 25, 183; DSM-​5 criteria 74–​75, 79, 80, 81; methods and 5–​6; pain and 134; risk factors and 135; skin-​picking disorder (SPD) and 94, 99, 100; and suicidality 26, 27, 114, 115–​117, 137, 138, 185, 187 sexual abuse 23–​24, 25, 118, 131, 166, 167, 171, 172 SHBQ (Self-​Harm Behavior Questionnaire) 140 Shearer, S. L. 110 Shek, D. T. L. 28 Shedding Light on Self-​Injury program 201 SHI (Self-​Harm Inventory) 140 Signs of Self-​Injury Program see SOSI SiOS see Self-​Injury Outreach and Support SIQ (Self-​Injury Questionnaire) 141 SITBI (Self-​Injurious Thoughts and Behaviors Interview) 138–​139 skin-​cutting 5–​6; app and 52; early research on 72; case studies 184–​185, 188, 189, 210; and gender 30; location of 131; severity 129–​130; and suicidality 29, 117 skin-​picking disorder see SPD sleep, lack of 133

SMHPs (school mental health professionals) 175–​176, 178–​179, 182 social communication function 30 social contagion 9–​10, 134, 179–​182, 185, 204, 217, 223–​224 social context, assessment of 26, 134–​135 social exclusion 47, 64–​65 social functions see interpersonal functions social media 144, 187, 203, 210–​211, 223, 226 social modeling 9, 218, 222–​224 social networks 195–​196, 227 social signaling hypothesis 222 social stressors 63, 64–​65, 66 social support 22, 78, 95, 134, 198, 226, 229 somatosensory cortices 42 Somer, O. et al. (2015) 29 SOS (Sources of Strength) program 227, 229, 230 SOSI (Signs of Self-​Injury Program) 215, 225–​226, 229, 230 SPD (skin-​picking disorder) 89–​100; acceptance and commitment therapy (ACT) and 96; body dysmorphic disorder (BDD) and 91–​92; cognitive behavioural therapy (CBT) and 96; decoupling (DC) and 97; habit reversal training (HRT) and 95; obsessive compulsive disorder (OCD) and 89–​91; severe 99, 100; subtypes 99; and trichotillomania (TTM) 92–​93 SRI (clomipramine) 97 SSI (suicidal self-​injury) 4, 5, 109–​119, 132; acquired capability for suicide 114–​116; age of onset 114; assessment measures 109–​110; characteristics as predictors 28–​30; co-​occurrence of NSSI and 111–​113; distinctions between NSSI and 110–​111; gateway theory 114; methods 30, 110–​111; predictors of 116–​119; third variables 113–​114 SSRIs (selective serotonin reuptake inhibitors) 97 St. Germain, S. A. 50, 51 stabilizing function 8–​9 stages of change model (transtheoretical model) 136 Stanley, B. et al. (2010) 61 Stein, D. J. et al. (2002) 99

248 Index stigmatization: minimization of 217, 228, 232; schools and 179, 181, 187, 188; and severity of NSSI 80; and use of internet 159, 197, 199, 201, 203 Stockholm, Regional Ethical Review Board 154 STOPS FIRE model of assessment 138 strengths, assessment of 137 stress 22, 30, 60, 63–​66, 152, 184, 221 stress-​related bodily disorders 63 Strong Kids program 228, 229, 231 substance use 11, 19, 25, 89, 133, 135 suicidal ideation: assessment of 137–​138; demographic variables 118–​119; ideation-​to-​action theories 21; NSSI and 21–​22, 29–​31, 74, 84, 112–​113, 115, 116–​117, 135, 167; prevention measures and 227; proxy variables 78, 80; self-​report measures 140 suicidality 21, 25–​27, 29, 109, 111–​112, 113–​116 Suicide Attempt Self-​Injury Interview see SASII suicide attempts 109–​119; assessment of 139, 140; case studies 172, 187; co-​occurrence with NSSI 111–​113; distinction between NSSI and 110–​111; Interpersonal–​ Psychological Theory of Suicidal Behavior 21, 114–​115; label of 4; and NSSI 21, 28–​30, 79, 80, 82, 113–​116, 136; neurobiology 61 Svedin, C. G. 9 Sweden 74, 152, 153–​156, 159 technology see apps; internet thalamus 62 Tiefenbacher, S. et al. (2005) 63 tissue damage 3, 45, 91, 94, 114, 129–​131, 134 tolerance, assessment of 131–​132

tools 130 trait anger 30 transdiagnostic approach 11, 20, 48, 65, 88, 219 transtheoretical model see stages of change model trichotillomania see TTM Trier social stress task 64 triggering 170, 180–​181, 189, 201, 202–​203, 210–​211, 222–​223 TTM (trichotillomania) 91, 92–​93, 95–​97, 98 Turner, J. M. 138 Tylenol see acetaminophen USA, confidentiality 184 validation 181, 197, 208, 210 variability over time 27–​28 Vaughn, M. G. et al. (2015) 23–​24 Victor, S. E. 118 Victor, S. E. et al. (2017) 79 violent behaviors 24 vulnerability-​stress theory  223 Walsh, B. W. 143, 166–​167, 168, 169–​170 Waltz, J. 99 Wang, B. et al. (2016) 28 Washburn, J. J. et al. (2015) 74, 78 Whitlock, J. 217, 222 Whitlock, J. et al. (2008) 129 Willoughby, T.  26, 27 Xin, X. et al. (2016) 26 You, J. 113 YouTube 180, 199, 202, 203, 210 Zettergvist, M. 9 Zetterqvist, M. et al. (2013) 79