Non-suicidal self-injury among adolescents: Diagnostic correlates and relation to suicide attempts
Introduction
Self-injurious behavior (SIB) refers to a broad class of behaviors in which an individual directly and deliberately causes harm to herself or himself. Such behavior can include non-suicidal self-injury (NSSI), which refers to direct, deliberate destruction of one's own body tissue in the absence of intent to die; or suicide attempts, which refer to direct efforts to intentionally end one's own life. Some authors have noted the theoretical, methodological, and clinical importance of distinguishing among various forms of SIB (O'Carroll et al., 1996, Linehan, 1997); and these suggestions have been supported by empirical studies demonstrating that self-injury-related constructs differ in their correlates (Nock and Kazdin, 2002, Nock and Kessler, in press) and functions (Brown et al., 2002). Although it is clear that NSSI and suicide attempts represent distinct behavioral phenomena, several important questions about NSSI and its relationship to suicide attempts are yet to be explained.
First, many fundamental characteristics of NSSI remain unknown. Indeed, the vast majority of prior work on SIB has focused on suicidal ideation and suicide attempts, with only a paucity of research addressing NSSI. For instance, it has been suggested that adolescents engaging in NSSI have higher rates of internalizing disorders (e.g., Ghaziuddin et al., 1992), and also may be at increased risk for a wider range of other cognitive, affective, and behavioral symptoms (e.g., Guertin et al., 2001); however, information about the diagnostic correlates of NSSI is lacking. Such information would be very useful for determining how NSSI corresponds with disorder currently listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association, 1994), especially given recent suggestions that NSSI should be considered for inclusion as a new DSM-IV diagnosis (Pattison and Kahan, 1983, Muehlenkamp, 2005).
Even less research attention has been given to the presence of personality disorders among adolescents who engage in NSSI. Although there is debate about the validity or appropriateness of diagnosing personality disorders before adulthood, the current edition of the DSM indicates they may be diagnosed when “maladaptive personality traits appear to be pervasive, persistent, and unlikely to be limited to a particular developmental stage or an episode of an Axis I disorder” (American Psychiatric Association, 1994, p. 631). Moreover, prior work has shown that the prevalence and the structure of personality disorders among adolescents resemble those in adulthood, and that the presence of a personality disorder during adolescence significantly increases the risk of subsequent disorders, providing validity for the application of such diagnoses (Bernstein et al., 1993, Westen et al., 2003). Although NSSI is most often associated with borderline personality disorder (BPD; Dulit et al., 1994, Shearer, 1994), the rate of BPD among adolescents engaging in NSSI is not known, nor is the rate of other personality disorders in this population. Overall, a systematic examination of Axis I and Axis II diagnoses among adolescents with a recent history of NSSI would be informative to both scientists and clinicians working with adolescent self-injurers.
Second, although NSSI and suicide attempts are distinct behavioral phenomena, they often co-occur within individuals (Dulit et al., 1994, Brown et al., 2002), yet it is unclear why this is so. Gaining a better understanding of what percentage of those engaging in NSSI also make suicide attempts, as well as why these behaviors are related, is a necessary step in helping clinicians identify and intervene with individuals at risk for multiple forms of SIB. The identification of aspects of NSSI that are associated with suicide attempts would be particularly useful given the dangerousness and lethality of these behaviors.
Why would individuals who engage in NSSI be at elevated risk for suicide attempts? Joiner (2005) recently advanced a comprehensive theory of SIB that makes several specific hypotheses about why individuals with a history of NSSI might engage in suicide attempts. He proposed that because suicide is such a frightening and extreme action, most people initially lack the ability to engage in suicide attempts. Individuals may become more courageous, competent, and willing to make suicide attempts with repeated engagement in NSSI and may even experience increasing reinforcement in the process (e.g., many patients report that self-injury has calming effects; see Haines et al., 1995). In other words, a negative side effect of engaging in NSSI may be that individuals habituate to the fear and physical pain associated with self-injury, thus acquiring the capability to perform lethal self-injury. As a test of this theory, we would hypothesize that those with a longer and more extensive history of NSSI (i.e., greater frequency, longer duration, and use of more methods of NSSI) should make suicide attempts more often than those without such a history.
The fundamental propositions of this model also draw upon previous research on pain analgesia among those engaging in SIB. Prior studies have demonstrated that some individuals report experiencing minimal or no pain during repetitive NSSI, despite clear and sometimes severe tissue damage (e.g., Nock and Prinstein, 2005). Differences in the experience of pain also are evident in behavioral laboratory tasks measuring pain threshold and tolerance. For instance, women diagnosed with borderline personality disorder (BPD) who report analgesia during NSSI have a higher pain threshold and pain tolerance on laboratory tasks (e.g., the cold pressor task) than women with BPD who report pain during NSSI (Russ et al., 1992), those who have no history of NSSI (Kemperman et al., 1997), depressed psychiatric inpatients (Russ et al., 1999), and healthy controls (Bohus et al., 2000). Similarly, several studies have demonstrated pain analgesia among recent suicide attempters. Orbach et al. (1997) found that adolescent suicide attempters (excluding those who had engaged in NSSI) have higher thermal pain thresholds and greater pain tolerance than non-suicidal adolescent inpatients and healthy control subjects. In addition, Orbach et al. (1996) reported that individuals visiting an emergency room following a suicide attempt endured more electric shocks and reported less physical pain than healthy control subjects or those admitted for accidental injuries. Taken together, these findings provide converging evidence for increased pain threshold and tolerance in those engaging in NSSI and suicide attempts. As a further test of the model described above, we would hypothesize that adolescents reporting less physical pain during NSSI would have less of an aversion to engaging in SIB and thus would have a history of engaging in more frequent NSSI, would report using a greater number of NSSI methods, and would make suicide attempts more often than those who experience physical pain during NSSI.
The primary goals of the current study were to (1) examine the diagnostic characteristics of adolescents with a recent history of NSSI, and (2) provide an initial, cross-sectional examination of the hypothesized relations between NSSI, suicide attempts, and physical pain in a sample of adolescent inpatients with a recent history of NSSI. Notably, the current study is cross-sectional and therefore is not able to test the temporal relations between NSSI, suicide attempts, and the experience of physical pain. Instead, this study represents an initial, exploratory evaluation of the relations hypothesized above that can, if supported, be evaluated using a prospective design.
Section snippets
Participants
Participants in the current study were 89 (23 males, 66 females) adolescents (12–17 years; M = 14.7, S.D. = 1.4) selected from consecutive admissions to an inpatient psychiatric unit who reported engaging in NSSI in the previous 12 months. Participants self-identified as 76.4% European American, 8.9% Latin American, 4.5% African American, and 10.1% Mixed Ethnicity/Other adolescents. According to state census tract data, socioeconomic status for adolescents in this sample was: 3.0% High, 57.6%
Diagnostic correlates of NSSI
Axis I diagnoses for the current sample of adolescent inpatients with a recent history of NSSI are reported in Table 1. Overall, 87.6% met criteria for at least one DSM-IV diagnosis (M = 3.0; S.D. = 2.2; range = 0 to 8 diagnoses). Although slightly more than half of the adolescents met criteria for an internalizing disorder (51.7%), most also met criteria for an externalizing disorder (62.9%) and a substance use disorder (59.6%). Examination of the specific substances used reveals that the majority
Discussion
This study examined the diagnostic correlates of NSSI and evaluated the relations between NSSI, suicide attempts, and the experience of physical pain among adolescent psychiatric inpatients. Several important findings warrant brief comment. These findings suggest that adolescents with a recent history of NSSI are a diagnostically diverse group, with more than half meeting DSM-IV criteria for an internalizing disorder, an externalizing disorder, and a substance-related disorder. Although it may
Acknowledgments
Support for this work was provided in part by a grant from NIMH (MH11770) to MJP. The authors would like to thank Dana Damiani and Joy Richmond for their assistance with data collection and Elizabeth Holmberg for her assistance in preparing the manuscript.
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