Non-Suicidal Self-Injury Among Adolescents and Young Adults in Africa: A Multi-Method Systematic Review

Early Adolescent Non-Suicidal Self-Injury and Sensory Preference Differences: An Exploratory Study by Jacquelyn S. Christensen Claremont Graduate University: 2012 BACKGROUND: Non-suicidal self-injury (NSSI) occurs in 13% to 20% of adolescents, and is often indicative of deeper internal or social problems. A close review of current explanatory models of NSSI suggested that underlying individual sensory preferences may contribute substantial explanations for the self-regulatory functions of NSSI, as well as have implications for treatment approaches. In the context of integrating sensory processing models with prominent functional NSSI models, this dissertation research compared sensory preferences in youth who engaged in NSSI to sensory preferences of youth who did not engage in NSSI. OBJECTIVE: NSSI-engaging youth were hypothesized to have lower threshold sensory preferences (sensation avoiding and sensory sensitive), and higher sensitivity (low threshold) in touch processing, auditory processing, and modulation of sensory input affecting emotional response. Sensory preferences were hypothesized to predict NSSI functionality, and trauma history and symptomology were hypothesized to predict NSSI and sensory preferences. METHODS: Youth (n = 108; 56% female; 43% Hispanic) aged 8-14 completed selfreport items regarding knowledge, thoughts, and engagement in NSSI, the Functional Assessment of Self-Mutilation (FASM) to evaluate type and functionality of NSSI, and the Adolescent / Adult Sensory Profile to evaluate sensory preferences (low registration, sensation seeking, sensory sensitive, sensation avoiding). Parents (90% female; Mage = 39.4 (SD = 6.9)) completed the Sensory Profile as a secondary measure of youth sensory preferences and the UCLA post-traumatic stress disorder reaction index (PTSD-RI) to evaluate youth trauma history and symptomology. RESULTS: NSSI-engaging youth (N = 14) scored significantly higher than Non-NSSIengaging youth (N = 85) in the sensation avoiding (Cohen’s d = .83) and low registration (Cohen’s d = .66) domains. Auditory sensitivity (youth-reported) significantly predicted NSSI after controlling for age. While parent-reported sensory preferences and trauma history and symptomology were not predictive of NSSI, auditory sensitivity (parent-reported) predicted PTSD symptomology in youth with trauma history. CONCLUSIONS: Results provide preliminary insight into better understanding the selfregulatory role of NSSI, and offer insight into specific sensory preferences of young adolescents who engage in NSSI. In combination with future research, findings contribute to existing comprehensive models of NSSI, and provide evidence for sensory considerations in NSSI treatment. DEDICATION In memory of Dr. Enid Gruber, my mentor and friend, who nurtured my love of research and learning. I will always remember our trip to Hawaii for my first conference. Even though you are gone, I know you are proud of me. For Dr. Joye Swan who told me to ask myself, “What would I do today if I was brave?” And to all of those who struggle with self-injury. This, and much of my future research, is for you.

Prospective Prediction of Nonsuicidal Self-Injury: A 1-Year Longitudinal Study in Young Adults

Objectives This study explored the associations between domains of experiential avoidance and severity and functions of non-suicidal self-injury (NSSI). Methods Undergraduates reporting a history of repeated engagement in NSSI (N = 150) completed measures of experiential avoidance, psychopathology, and self-injury. Results Procrastination, a specific domain of experiential avoidance, was related to the severity of self-injurious behavior; however, procrastination did not account for significant incremental variance in the NSSI severity over and above the contributions of depression and anxiety. Correlational and hierarchical regression analyses indicated that procrastination and repression/denial domains of experiential avoidance were associated with automatic negative and automatic positive reinforcement functions of NSSI (respectively) and accounted for significant incremental variance after controlling for depressive and anxiety symptoms. Both repression/denial and distress aversion also explained a significant proportion of variance in engagement in NSSI for interpersonal reasons when controlling for the contributions of depression and anxiety. Conclusions These findings provide preliminary support for the notion that unique relationships exist among distinct forms of experiential avoidance and both severity and functions of NSSI. Clinical and theoretical implications for these results are discussed.

<p>Non-Suicidal Self-Injury (NSSI) is defined as the intentional, direct injury to body tissue, undertaken without suicidal intent, and for a purpose that is not socially or culturally sanctioned (International Society for the Study of Self-Injury, 2007; Klonsky & Muehlenkamp, 2007; Muehlenkamp, 2014). NSSI is prevalent in adolescent samples worldwide (Muehlenkamp, Claes, Havertape, & Plener, 2012; Swannell, Martin, Page, Hasking, & St John, 2014) and is typically considered a marker of wider distress. NSSI in adolescents has been associated with numerous poor mental health outcomes, including depression, anxiety, substance abuse, eating disorders, and attempted and completed suicide (Asarnow et al., 2011; Brunner et al., 2014; Claes, Soenens, Vansteenkiste, & Vandereycken, 2012; Fox et al., 2015; Glenn & Klonsky, 2011; Jacobson & Gould, 2007). In addition, research has demonstrated that perfectionism, defined as the setting of excessively high standards of performance (Frost, Marten, Lahart, & Rosenblate, 1990), is also commonly associated with substantial distress. Unfortunately, perfectionism in adolescents is thought to be on the rise (see Flett & Hewitt, 2014; Portesova & Urbanek, 2013) with many adolescents reporting multi-sourced and relentless pressure to perform highly and adhere to societal ideals. As such, individuals are setting excessively high goals for themselves, and increasingly worrying about the consequences of less than perfect performance. Similar to the research pertaining to NSSI, perfectionism has been shown to also be associated with a raft of poor outcomes including depression, anxiety, eating disorders, and general psychological distress (e.g., Boone, Braet, Vandereycken, & Claes, 2013; Claes et al., 2012; DiBartolo et al., 2007; Lombardo, Mallia, Battagliese, Grano, & Violani, 2013; Vartanian & Grisham, 2011). Research has shown an association between NSSI and perfectionism (e.g., Hoff & Muehlenkamp, 2009; O’Connor, Rasmussen, & Hawton, 2010). However, this literature is currently very limited and the relationship between NSSI and perfectionism is not well understood. In light of this, I set out to thoroughly explore if, and how, NSSI and perfectionism are related in New Zealand adolescents. Moreover, I aimed to gain insight into the mechanisms that could underpin such relationships. Of the four studies conducted, the first and second studies established a foundation for my research. Specifically, Study 1 meta-analyses synthesised data from 118 studies investigating the relationship between perfectionism and adaptive and maladaptive outcomes. These analyses demonstrated a robust relationship between negative perfectionism and maladaptive outcomes. More specifically, they revealed a significant, positive summary correlation for the relationship between negative perfectionism and self-injurious thoughts and behaviours. Study 2 aimed to define the most appropriate conceptualisation of perfectionism for research with New Zealand adolescents. This involved investigating the psychometric properties and factor structure of the Frost Multidimensional Perfectionism Scale (Frost et al., 1990) in 930 adolescents with a mean age of 14 years old. A hierarchical structure with two overarching components (positive perfectionism, negative perfectionism), comprised of four second-level components (concerns and doubts, parental pressure, personal standards, and organisation) was identified and adopted for all following research. Studies 3 and 4 investigated the cross-sectional and longitudinal relationships between NSSI and perfectionism. Study 3a specifically aimed to ascertain whether negative and positive perfectionism are associated with NSSI in New Zealand adolescents, based on survey data from 930 adolescents in their second year of high school. As expected, negative perfectionism was significantly associated with NSSI in females, however this relationship did not hold for males. On the other hand, positive perfectionism was associated with less engagement in NSSI in both males and females. This suggested that negative perfectionism may represent a risk factor for NSSI, while positive perfectionism may buffer against risk of NSSI. In addition, Study 3b investigated the relationships between perfectionism and the functions of NSSI, indicating that self-punishment functions are particularly relevant for perfectionistic adolescents. As the final component of the cross-sectional analyses, Study 3c illustrated that the association between perfectionism and NSSI is more accurately captured when the interaction between positive and negative perfectionism is also considered. Study 4 involved the examination of this relationship over time. To do so, another wave of data was collected, resulting in data matched across two times points for 608 adolescents. Longitudinal analyses demonstrated that negative perfectionism prospectively predicted NSSI one year later in females only. Moreover, again for only females, positive perfectionism predicted an increase in negative perfectionism over time. No significant longitudinal relationships were demonstrated for male adolescents. The ultimate aim of this research was to provide clinicians, school staff and parents with the information required to effectively identify at-risk adolescents, and thereby prevent the onset of NSSI and its vast associated negative outcomes. This research suggests that perfectionism is one such risk factor to be aware of. As such, it is argued that targeted prevention and intervention strategies for perfectionism will help prevent the onset and maintenance of NSSI in females, and are also likely to be of benefit to the wider mental wellbeing of New Zealand adolescents.</p>

ABSTRACTS Objective The current study aimed to investigate the sociodemographic and psychological variables as well as the function of NSSI related to the cessation of NSSI by analyzing the difference between those currently engaged in nonsuicidal self-injury (NSSI) and those who have stopped NSSI behaviors. Methods A total of 490 adults with a history of NSSI (359 females) were assigned to one of two groups: NSSI engagement within the last 12 months or “current NSSI” (n = 402) vs. no episode of NSSI in the previous 12 months or “lifetime NSSI” (n = 88). Results There were no significant group differences in sex or socioeconomic status, while individuals with current NSSI were slightly younger than those who had ceased NSSI behavior. Regarding the functions of NSSI, the current NSSI group endorsed more intrapersonal functions. Moreover, the participants who had ceased NSSI behavior reported significantly less perceived stress, dysfunctional attitudes, alexithymia, emotion reactivity, and suicidal ideation. On the other hand, the lifetime NSSI group showed greater psychological resources such as self-esteem, distress tolerance, and resilience. Conclusions We revealed apparent differences in NSSI functions, clinical symptoms, and psychological resources depending on the maintenance and cessation of NSSI. This study highlights the need for a better understanding of the factors that stop as well as those that continue NSSI behaviors. HIGHLIGHTS The lifetime NSSI group reported more intrapersonal NSSI functions. The current NSSI group suffered from more clinical symptoms. Individuals who ceased NSSI had more psychological resources.

Exploring the role of anger in nonsuicidal self-injury in veterans

Although nonsuicidal self-injury (NSSI) is more common among military veterans than adult civilians, little is known about NSSI disorder among veterans. The present study explored NSSI characteristics among veterans meeting criteria for current NSSI disorder (N = 41) and the relationship between NSSI methods and functions. Participants reported a pattern of past-year NSSI engagement characterized by frequent and severe NSSI, a short interval between NSSI urges and behavior, and moderate or greater subjective distress and interference in family relationships, social relationships, and work/school. Psychiatric comorbidities were common, and nearly half of participants reported a suicide attempt history. Participants used an average of four NSSI methods, the most common being wall-punching (85.4%), and endorsed an average of eight distinct functions of NSSI, predominantly for intrapersonal reasons. Regardless of the specific method used, the most common reason that veterans with NSSI disorder engaged in NSSI was to help themselves cope with negative emotions. Findings suggest certain NSSI characteristics are similar among veterans and civilians with current NSSI disorder (e.g., NSSI functions) and differ between them (e.g., NSSI methods). Further research is necessary in order to replicate and expand upon these findings with nationally representative samples and better understand NSSI functions among veterans.

Emerging evidence suggests that alexithymia, a psychological construct defined by the inability to describe emotion, differentiate feelings, and think in an internally oriented way, may be relevant in understanding engagement in nonsuicidal self-injury (NSSI). However, there is a paucity of longitudinal work on alexithymia and NSSI, which is necessary to discern whether alexithymia may heighten risk for NSSI over time. In the present study, the association between alexithymia and NSSI was examined among 1125 emerging adults (Mage = 17.96, 72% female), who completed a survey at two time points 4 months apart. Participants with a history of NSSI reported higher levels of alexithymia than those with no NSSI engagement. A zero-inflated negative binomial regression model revealed that higher alexithymia at Time 1 predicted greater diversity in NSSI methods (i.e., NSSI versatility), but not NSSI frequency, at Time 2, for those already engaging in NSSI (p < 0.01, controlling for NSSI history at Time 1, emotion regulation difficulties, age, and gender). Significant differences were found in NSSI functions based on alexithymia among individuals with a lifetime history of NSSI at both time points. Among participants with a history of NSSI, alexithymia was most strongly correlated with anti-dissociation, sensation seeking, self-punishment, toughness, and interpersonal boundaries NSSI functions. Findings underscore that alexithymia may be relevant to understanding NSSI severity.

BackgroundYoung adults are a high-risk group for nonsuicidal self-injury (NSSI). It is important to have a better understanding of these behaviors in order to facilitate effective research, intervention, and treatment. Models have been presented to explain these behaviors where emotion regulation, coping, and support play a role. Yet conflicting results have occurred based on demographic factors such as race and sex. While controlling for the observable demographic factors, this study sought to examine differences between individuals who currently engage in NSSI, engaged in NSSI in the past, and never engaged in NSSI related to emotions, coping strategies, interpersonal support, and ethnic identity and belonging.MethodsParticipants were selected from freshman students at two universities, in geographically different locations in the United States (N = 282). Participants in this study were matched on demographic factors: race, sex, and university. This led to demographically matched groups (current, past, never engagement in NSSI; n = 94 per group). Groups were compared on intrapersonal factors (i.e., emotions: depression and anxiety; coping strategies: adaptive and maladaptive; interpersonal support: family, friend, and significant other; and ethnic identity and belonging). Descriptive statistics and ANOVA with post hoc Scheffe were utilized to explicate differences between groups.ResultsIndividuals who never engaged in NSSI reported significantly higher levels of ethnic belonging and interpersonal support and lower levels of depression and anxiety than both groups who engaged in NSSI. Individuals who never self-injured used less adaptive and maladaptive coping strategies than participants who self-injured. Young adults who currently engaged in NSSI reported higher levels of depression and anxiety, higher levels of both types of coping, and perceived less support.ConclusionsIt is important to understand the differences between individuals who self-injure in comparison to those who do not so that mental health clinicians can provide more effective services and preventative efforts.

Adverse childhood experiences and their impact on frequency, severity, and the individual function of nonsuicidal self-injury in youth

The present study examines whether dimensions of pathological narcissism are associated with the presence, frequency, and function of nonsuicidal self-injury (NSSI). Adults (N = 252) completed questionnaires assessing narcissistic grandiosity, narcissistic vulnerability, fluctuation between these narcissistic states, and borderline personality disorder (BPD) symptoms. Those with a history of NSSI (n = 105) also reported the method, frequency, and function of their NSSI engagement. When controlling for co-occurring BPD symptoms, there were very few associations between vulnerability, grandiosity, and narcissistic fluctuation and NSSI presence and frequency. However, a clear pattern emerged regarding NSSI functions. Although vulnerability and narcissistic fluctuation were not associated with any functions of NSSI when co-occurring BPD symptoms were controlled for, grandiosity was positively associated with all interpersonal functions of NSSI (e.g., peer bonding, revenge) and negatively associated with the intrapersonal function of affect regulation. These results suggest a unique relationship between narcissistic grandiosity and NSSI that may inform clinical intervention.

Objective Non-suicidal self-injury (NSSI) is strongly associated with difficulties in emotion regulation, but its relationships with maladaptive cognitive processes are less clear. Method The current study examined relationships between self-reported NSSI (presence, number of methods, frequency, recency, duration, functions) and negative cognitive processes (rumination, worry, self-criticism, perceived burdensomeness, thwarted belongingness) among 1,357 undergraduates. Cognition variables were submitted to exploratory factor analysis (EFA), and relationships were examined between the resulting factors and NSSI history (among the full sample) and NSSI severity and functions (among those with a history of NSSI). Results The EFA derived two higher order cognitive factors: repetitive negative thinking (RNT) and negative self-perception (NSP). Both RNT and NSP were significantly higher among participants with than those without a history of NSSI. Among those with NSSI, NSP, but not RNT, was positively related to lifetime NSSI frequency and number of methods, as well as recency (presence in the past 12 months) and total duration (in years) of NSSI engagement. Moreover, RNT and NSP were positively associated with aggregate intrapersonal (but not interpersonal) functions of NSSI. The two cognitive factors demonstrated differential relationships with the individual intrapersonal NSSI functions. Conclusions Higher order categories of cognitive risk factors may have unique relationships with functions and severity of NSSI, with possible implications for more targeted approaches to risk assessment and intervention. Highlights Negative thinking and self-perception were higher in people who engage in NSSI. Negative self-perception was associated with greater NSSI severity. Negative thinking and self-perception had different relations to NSSI functions.

Non-suicidal self-injury (NSSI) has been associated with an array of difficulties such as childhood abuse, interpersonal conflict, and mental health concerns ranging from emotional distress to suicidal thoughts and urges. To improve our understanding of NSSI and its relation to suicide risk, this study assessed the demographic (age, sex) and clinical (anxiety, depression, suicidal ideation, suicide attempt history) characteristics associated with NSSI methods (“how”) and functions (“why”). The study sample (N = 193) included youth and young adults, ages 13 to 25, who were seeking emergency psychiatric services and endorsed a lifetime history of NSSI. Study participants completed questionnaires assessing depression, anxiety, suicidal ideation, history of suicide attempt, and characteristics of NSSI engagement. Data were analyzed using Pearson, Spearman, and point-biserial correlation, Mann-Whitney U test, chi-square, t-test, and regression analyses (Poisson, binary-logistic, and ordinal). Female sex, the most prominent correlate in this study, was associated with number of lifetime NSSI incidents, quantity of NSSI methods used, and frequency of NSSI function engagement. Lifetime history of suicide attempt and suicidal ideation were positively associated with numbers of NSSI methods and functions, respectively. Regression analysis indicated that number of NSSI methods was associated with suicide attempt history, whereas total number of NSSI incidents was not. A greater understanding of the demographic and clinical factors associated with NSSI may ultimately advance the assessment and treatment of this behavior, especially in relation to suicide risk.

The implicit association hypothesis of nonsuicidal self-injury (NSSI) proposes that individuals who engage in self-injury develop, over time, strong associations between themselves and NSSI, and their identification with this behavior guides their future selection of NSSI to cope. Prior research has established a relationship between implicit NSSI associations (using an Implicit Association Test for Self-Injury) and engagement in NSSI. However, previous studies have been small and cross-sectional, and thus underpowered to examine the nature of this association and the extent to which implicit associations predict the persistence of NSSI. This study builds on previous research in a prospective, longitudinal examination of implicit self-identification with NSSI in a large sample of middle school students. NSSI behavior and implicit NSSI associations were assessed annually in school at three time points. Adolescents who engaged in NSSI exhibited stronger implicit self-identification with NSSI than adolescents who did not engage in NSSI. Moreover, implicit NSSI identification was stronger among adolescents who engaged in cutting, frequent NSSI, and recent NSSI. A reciprocal association was observed between NSSI frequency and implicit NSSI identification over 1year. Notably, implicit NSSI identification uniquely and prospectively predicted engagement in NSSI over the subsequent year. Implicit self-identification with NSSI may track both trait- and state-related changes in the behavior and, importantly, may help predict continued engagement in NSSI.

Non-suicidal self-injury (NSSI), a new disorder included in the for further study section of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders [1], refers to a deliberate behavior that directly damages one's own body tissue without suicidal intention [2]. This behavior has become a major public health concern among adolescents, affecting about 18% of community adolescents all over the world [3]. This high prevalence of NSSI may make people wonder why so many adolescents engage in this behavior. We may think that NSSI must cause physical pain. It is against the innate and evolutionary drive of self-preservation. However, although getting involved hurting oneself, as many as 80% of adolescent self-injurers reported little or no pain while engaging in the act [4]. Laboratorial studies using various NSSI proxies (e.g., cold, heat, electric shock) also provided supports for the diminished pain perception in individuals with NSSI [5,6]. Regarding the mechanism underlying the relationship between diminished pain perception and NSSI, studies suggested that emotion dysregulation and self-invalidation may act as potential mediators [7,8]. Apart from the abnormal physical pain perception, the engagement in NSSI also involves social pain dysregulation. Social pain is associated with actual or potential damage to one's sense of social connection or social value and is often described by the language of physical pain (such as broken hearts, or hurt feeling) across a variety of cultures [9,10]. Interpersonal disturbances, particularly in the family context, may influence the development of NSSI in adolescence [11]. It is suggested that the overall quality of attachment with parents in childhood, injury in parent-child bonds, and experiences of separation and loss may contribute to later NSSI [11-13]. Additionally, maternal emotional neglect (e.g., lack of maternal care), paternal insecure attachment, lack of intimacy within the parent-child relationship, and family invalidation were reported to be associated with NSSI [12,14-16]. In short, when there are problems in parent-child relationships, which are the most important social connections, individuals may suffer social pain, which may then lead to the engagement in NSSI. Non-suicidal self-injury is not the privilege of humans. Other animals may also engage in NSSI. It is thus meaningful to explore this phenomenon in non-human primates, even in other mammals [17]. Approximately 10% of animals under individual caging (i.e. social isolation) engage in NSSI [18]. Isolated animals, both with and without abnormal rearing, may exhibit NSSI. Besides, the duration of isolation, and the beginning age of isolation may play a key role in determining the extent of risk for later developing NSSI [19]. Previous research suggests that both physical pain and social pain dysregulations may be involved in NSSI. In fact, considerable evidence has been showing that social pain shares parts of the same phenomenological, neurological, and psychological systems with physical pain [10,20]. We thus speculate that one important function of NSSI may be social pain regulation, by means of inflicting physical pain on the body. Several studies have provided preliminary evidence for this speculation, such that acute physical pain (NSSI-proxy) was found to lead to emotional benefits [2,21,22]. Additionally, only under conditions of interpersonal distress did heightened physical pain tolerance among self-injurers occur [23]. Therefore, although most past studies focused on the emotion regulation function of NSSI [24,25], we suggest future research to consider pain regulation as an important mechanism underlying the engagement in NSSI. Language: en