Do styles of emotion dysregulation differentiate adolescents engaging in non-suicidal self-injury from those attempting suicide?
Introduction
Suicide is currently the second leading cause of death among 13–18-year olds. Yet, completed suicides are just one part of the larger public health crisis, with even more children making suicide attempts (SA) or having recurrent suicidal ideation (SI) (Centers for Disease Control and Prevention [CDCP], 2016). That is, according to the 2017 Youth Risk Behavior Survey, during the year prior, 17.2% of high school students nationwide seriously contemplated suicide, 13.6% made a suicide plan, 7.4% made an SA, and 2.4% made an SA that required medical treatment (CDCP, 2018). Despite continued policy, research, and clinical efforts, suicide trends have remained largely unchanged for decades (Kann et al., 2016; Kann et al., 2018).
Non-suicidal self-injury (NSSI) is another form of self-harm defined as deliberately hurting one's own body tissue, dissimilar to SAs, without intent to die (O'Carroll et al., 1996). Epidemiological reports have shown alarming lifetime rates of NSSI among adolescents, ranging from 6% to 30% in community samples, whereas only 4–6% of adults endorse the behavior (Klonsky, 2011; Plener et al., 2009; Muehlenkamp et al., 2012). Adolescence may be a critical period for studying NSSI when considering its rates peak at this age and mortality risk is higher for teens compared to young adults (Jacobson and Gould, 2007; Olfson et al., 2018). While there are clear differences between NSSI and an SA—including frequency, prevalence, and function—there are also substantial areas of overlap. Approximately 40% of adolescents who self-injure have also made a lifetime SA (Whitlock and Knox, 2007), and NSSI is regarded as a robust predictor for future suicide behaviors (Asarnow et al., 2011; Klonsky et al., 2013; Wilkinson et al., 2011). In fact, NSSI provides a tenfold risk for future SA, even after accounting for previous SA and depressive symptoms (Wilkinson et al., 2011).
Unfortunately, most prior studies have used samples that engage in both NSSI and SA, perhaps not surprising given high rates of co-occurrence. For example, while one study compared typically developing controls (TDC) with a group of individuals having made an SA, they inconsistently included those who had also engage in NSSI (Nock and Kessler, 2006). Another study compared TDC with no SIB to those engaging in NSSI and to those with both NSSI+SA, yet no group of individuals with SA exclusive of NSSI (Brausch andGutierrez, 2010). There remains a great need to clarify factors that are specifically and uniquely related to NSSI vs. SA. The work of Stewart et al. (2017), comparing three groups of adolescents engaging in NSSI (i.e., non-ideators, ideators with no lifetime SA, ideators with lifetime SA), contributes to this shift in the field. They found that those with a lifetime attempt engaged in more NSSI methods and in more severe forms of NSSI (e.g., burning) compared to non-ideators. Continued focus is needed on disentangling the mechanisms underlying each form of SIB, such as emotion dysregulation, requiring comparative studies involving homogenous groups of people engaged in NSSI-only or SA-only, but not necessarily both NSSI+SA.
Emotion dysregulation is a transdiagnostic factor, cutting across psychopathology categories and implemented in the development, maintenance and exacerbation of child/adolescent psychopathology, including internalizing, externalizing and personality disorders (e.g., Aldao et al., 2010; Cicchetti et al., 1995; Glenn and Klonsky, 2009; Morris et al., 2010; Neumann et al., 2009; Valiente et al., 2007). Emotion dysregulation is more specifically implicated in both forms of self-injurious behaviors (SIB), clearly supported by the influx of research linking the construct as a precursor to NSSI, SA (Adrian et al., 2011; Rajappa et al., 2012) and other maladaptive and impulsive behaviors (McLaughlin et al., 2011). While there is agreement that emotion dysregulation acts as a risk factor for harmful behaviors, there is a lack of consensus about what features define it and how best to assess it. As a result, there are competing models over what these factors consist of, and how to measure them (Cole et al., 2004; Zeman et al., 2006). This is mirrored in the number of scales adopted to measure aspects of emotion dysregulation. In general, these models refer to poor understanding and awareness, low acceptance, and maladaptive management of emotions (Gratz and Roemer, 2004; Mennin et al., 2007). Previous studies analyzing the link between emotion dysregulation and self-injurious behaviors are limited because they only focus on a single assessment measure, or a few components of these constructs. For example, the Difficulties in Emotion Regulation Scale (DERS) indicated that one dimension, “beliefs about access to regulation strategies”, accounts for a greater variance in NSSI behaviors compared to other aspects of emotion dysregulation measured on the DERS (Perez et al., 2012).
The current study sought to probe how different assessments of emotion dysregulation might differentiate mutually exclusive groups of adolescents: (1) those who have made an SA, with no history of NSSI (SA-only); (2) those who have engaged in NSSI, with no history of an SA (NSSI-only); (3) community-recruited, TDC without any form of psychopathology including NSSI or SA. Specifically, we evaluated between-group differences on six measures of emotion dysregulation. Then, we tested whether specific dimensions of emotion dysregulation predicted group status by accounting for shared overlap across scales. We hypothesized that both SA and NSSI participants would have more severe emotion dysregulation profiles vs. TDCs. However, a priori hypotheses of how the NSSI and SA groups would differ were not set due to the novel design of directly comparing mutually exclusive NSSI and SA groups on multiple features of emotion dysregulation
Section snippets
Participants and procedure
The current IRB-approved study was conducted at an academic children's psychiatric hospital in the Northeast. After informed child assent and parental consent were obtained, 140 adolescent participants, ages 13–18, were enrolled into one of three mutually exclusive groups: (1) SA with no history of NSSI (SA-only group), (2) NSSI with no history of SAs (NSSI-only group), (3) community based TDCs with no history of psychiatric illness including NSSI and SA.
SA participants (n = 48) made an
Demographics
A number of participants were excluded from the initially recruited and consented N = 172. Specifically, N = 18 were excluded due to endorsing lifetime NSSI and SA, N = 5 were excluded due to endorsing NSSI lifetime frequency <5, N = 7 were excluded due to missing self- and/or parent-report forms, and N = 2 was excluded due to FSIQ<70 or missing. The remaining, combined sample primarily identified as female (70%), Caucasian (80.3%), and had an average age of 15.56±1.31 years. Intelligence for
Discussion
Our study addressing the need for research that integrates and compares measures of emotion dysregulation in SA and NSSI, overall, showed that adolescents who engage in such self-injurious behaviors have significantly more problems with regulating emotions than TDCs without psychopathology or self-injurious behavior. Importantly, while mean comparisons demonstrated significant deviations between NSSI and SA groups on distress tolerance and emotional reactivity measures, after controlling for
CRediT authorship contribution statement
Kerri L. Kim: Conceptualization, Validation, Investigation, Formal analysis, Writing - original draft, Writing - review & editing. Janine Galione: Conceptualization, Methodology, Formal analysis, Writing - original draft. Elana Schettini: Conceptualization, Formal analysis, Data curation, Writing - original draft, Project administration. Lena L.A. DeYoung: Validation, Formal analysis, Data curation, Writing - review & editing, Project administration. Anna C. Gilbert: Data curation, Project
Declaration of competing interest
The authors have no conflict of interest to report.
Acknowledgements
The authors would like to acknowledge the adolescents and their families who participated in this study. This study was funded by an American Foundation for Suicide Prevention Young Investigator Award to the senior author and internal hospital funds. No authors have biomedical financial interests or potential conflicts of interest.
References (62)
- et al.
Emotion-regulation strategies across psychopathology: a meta-analytic review
Clin Psychol Rev
(2010) - et al.
An investigation of persistence through pain and distress as an amplifier of the relationship between suicidal ideation and suicidal behavior
J Affect Disord
(2016) - et al.
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
(2011) - et al.
Impaired decision making in adolescent suicide attempters
Journal of the American Academy of Child & Adolescent Psychiatry
(2012) - et al.
Effectiveness of systemic family therapy versus treatment as usual for young people after self-harm: a pragmatic, phase 3, multicentre, randomised controlled trial
The Lancet Psychiatry
(2018) - et al.
Lethal forethought: delayed reward discounting differentiates high-and low-lethality suicide attempts in old age
Biol. Psychiatry
(2011) - et al.
The Children’s Affective Lability Scale: a psychometric evaluation of reliability
Psychiatry Res
(1996) - et al.
Schedule for affective disorders and Schizophrenia for school-age children-present and lifetime version (K-SADS-PL): initial reliability and validity data
J Am Acad Child Adolesc Psychiatry
(1997) - et al.
Behavioral and emotional responses to interpersonal stress: a comparison of adolescents engaged in non-suicidal self-injury to adolescent suicide attempters
Psychiatry Res
(2015) - et al.
Major depressive disorder in adolescents: family psychiatric history predicts severe behavioral disinhibition
J Affect Disord
(2006)
Emotion dysregulation and adolescent psychopathology: a prospective study
Behav Res Ther
Delineating components of emotion and its dysregulation in anxiety and mood psychopathology
Behav Ther
Behavioral assessment and treatment of self-injurious behavior in autism
Child Adolesc Psychiatr Clin N Am
Non- suicidal self-injury among adolescents: diagnostic correlates and relation to suicide attempts
Psychiatry Res
The emotion reactivity scale: development, evaluation, and relation to self-injurious thoughts and behaviors
Behav Ther
The end of family therapy for self-harm, or a new beginning?
The Lancet Psychiatry
Emotional reactivity and its impact on neural circuitry for attention–emotion interaction in childhood and adolescence
Dev Cogn Neurosci
Adolescent self-injurers: comparing non-ideators, suicide ideators, and suicide attempters
J Psychiatr Res
Emotional dysregulation and interpersonal difficulties as risk factors for nonsuicidal self-injury in adolescent girls
J Abnorm Child Psychol
An examination of disclosure of nonsuicidal self‐injury among university students
J Community Appl Soc Psychol
Functional Imaging of the Implicit Association of the Self With Life and Death
Suicide and Life‐Threatening Behavior
Differences in Non-Suicidal Self-Injury and Suicide Attempts in Adolescents
J Youth Adolesc
Emotions and emotion regulation in developmental psychopathology
Dev. Psychopathol.
Emotion regulation as a scientific construct: methodological challenges and directions for child development research
Child Dev
Self‐injurious implicit attitudes among adolescent suicide attempters versus those engaged in nonsuicidal self‐injury
Journal of child psychology and psychiatry
Development of a computerized adaptive test for depression
Arch. Gen. Psychiatry
Emotion dysregulation as a core feature of borderline personality disorder
J. Pers. Disord.
Multidimensional assessment of emotion regulation and dysregulation: development, factor structure, and initial validation of the difficulties in emotion regulation scale
J Psychopathol Behav Assess
The epidemiology and phenomenology of non-suicidal self-injurious behavior among adolescents: a critical review of the literature
Archives of Suicide Research
Nonsuicidal self-injury, suicidal behavior, and their co-occurrence as viewed through the lens of the Interpersonal Theory of Suicide
Curr Dir Psychol Sci
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