Printer Friendly

Features of psychopathology in self-injuring female college students.

Although research on nonsuicidal self-injury (NSSI) is accumulating, there is as yet little data on psychopathological features associated with NSSI in nonclinical samples. College students may be particularly susceptible to engaging in NSSI and NSSI may be phenomenologically and etiologically different for males and females. This archival study examined differences between college student women with (n = 34) and without (n = 32) a history of NSSI in scores on the clinical scales and subscales of the Personality Assessment Inventory (PAI). Multivariate analyses revealed significantly higher levels of depression, anxiety, borderline personality features, suicidality, and certain psychotic features in self-injurers. Follow-up analysis identified four symptom themes associated with NSSI across diagnostic categories: emotional distress, physiological distress, cognitive distortion, and interpersonal difficulties. This study confirms previous findings of higher levels of affective symptoms in self-injurers. Unique findings of this study included significantly higher scores for self-injurers on the PAI Thought Disorder, Psychotic Experiences, and Hypervigilance subscales. This suggests a need to expand the conceptualization of the clinical correlates of NSSI to encompass a broader array of symptomatology. Implications for clinical practice are discussed

INTRODUCTION

Nonsuicidal self-injury (NSSI) covers any behavior that results or is highly likely to result in immediate tissue damage without conscious intent to cause death, such as laceration, burning, scratching, and hitting oneself (Klonsky & Muehlenkamp, 2007; Silverman, Berman, Sanddal, O'Carroll, & Joiner, 2007). Silverman and colleagues have conceptualized NSSI as including self-harmful behaviors with the intent to cause damage but not death that may or may not actually produce physical damage to the individual. Rates of NSSI are posited to be increasing, especially among young adults (Hawton, Fagg, Simkin, Bale, & Bond, 1997; Whitlock, Eells, Cummings, & Purington, 2007). Previous research has documented substantially higher rates of NSSI (11-38%) in college populations (Gratz, 2001; Whitlock, Eckenrode, & Silverman, 2006) than in nonclinical adult populations, where rates of 4% have been reported (Briere & Gil, 1998; Klonsky, Oltmanns, & Turkheimer, 2003). Despite the higher rates among college student populations, there is a paucity of research pertaining to this age group.

Identification of risk factors is a primary goal for much of the current research into NSSI (see Klonsky & Muehlenkamp, 2007; Muehlenkamp, 2005). Among the risk factors identified are impulsivity (Simeon & Favazza, 2001); insecure parental attachment (Gratz, Conrad, & Roemer, 2002); and childhood physical and sexual abuse (Gratz et al.; Weiderman, Sansone, & Sansone, 1999). Psychopathologies such as borderline personality disorder (BPD; Brown, Comtois, & Linehan, 2002; Lieb, Zanarini, Schmahl, Linehan, & Bohus, 2004); mood disorders (Haw, Houston, Townsend, & Hawton, 2002); anorexia and bulimia nervosa (Claes, Vandereycken, & Vertommen, 2001); posttraumatic stress disorder (PTSD); and substance abuse (Zlotnick, Mattia, & Zimmerman, 2001) have also been documented as significant correlates of NSSI for both inpatients and outpatients. Yet there is still a dearth of data on specific psychopathological features of NSSI in community and college student populations. Bridging this gap is important for a more complete understanding of the emotional and psychological factors associated with NSSI.

The relationship between NSSI and BPD has received the most attention. There is clear evidence that in clinical settings a considerable number of individuals with BPD engage in NSSI, at rates as high as 80.7%--more than quadruple the rate found in those with other Axis II disorders (Zanarini, Frankenburg, Hennen, & Silk, 2003). However, it appears that only one study has examined BPD traits and NSSI in college students. Andover, Pepper, Ryabchenko, Orrico, and Gibb (2005) reported that college student self-injurers endorsed a significantly greater number (p<.001) of BPD symptoms than controls, and that BPD symptoms were more strongly associated with NSSI than depression or anxiety symptoms--that is, when controlling for BPD symptoms, differences in depression and anxiety between self-injurers and controls were not significant. This study was limited by the authors' decision to look at BPD to the exclusion of other disorders; there may be other elements of psychopathology related to NSSI that BPD does not account for.

There is evidence that depressive symptoms are positively correlated with NSSI (Briere & Gil, 1998; Haw et al., 2002). Estimates of individuals who engage in NSSI who also meet criteria for depressive disorders range from 31% to 70.7% (Briere & Gil; Ferreira de Castro, Cunha, Pimenta, & Costa, 1998; Haw et al.). However, these estimates are derived from clinical populations, ignoring a large and potentially unique proportion of the self-injuring population. Little is known about the possible relationship between depressive disorders and NSSI among college students. In their study of over 2,000 college students, Whitlock et al. (2006) found that self-injurers were more likely to report elevated distress (p<.001) and suicidal thoughts (p<.001) than were non-self-injurers, which suggests that depression may be involved. Yet specific symptoms of depression have not been studied. More recently, Polk and Liss (2007) found that depressive symptoms significantly (p<.001) differentiated self-injurers recruited from an Internet self-help site and non-self-injuring college students but did not significantly differentiate self-injuring college students from either Internet self-injurers or non-self-injuring college students. The association between depressive symptoms and NSSI among college students is at best unclear.

Although research to date has concentrated on examining both depression and BPD as risk factors for NSSI, other forms of psychopathology that may increase the risk of NSSI have been given little attention. For example, a number of anxiety-based disorders have been documented in self-injurers (Harued, Najavits, & Weiss, 2006; Haw et al., 2001; Ross & Heath, 2002; Simeon, Stein, & Hollander, 1995), although exploration of the contribution of anxiety symptoms to NSSI has been scant. Nonetheless, there is emerging evidence that anxiety may be a risk factor. Nixon, Cloutier, and Aggarwal (2002) reported that 71.4% of their self-injuring adolescent inpatient sample reported engaging in NSSI to "cope with nervousness or fear, " which was consistent with other reports from community adolescent samples (Laye-Gindhu & Schonert-Reichl, 2005). Furthermore, in a recent study of British college-age youth, Young, VanBeinum, Sweeting, and West (2007) found that participants were likely to engage in NSSI in order to reduce anxiety, suggesting that the role of anxiety requires further explication. Additional evidence for the NSSI-anxiety relationship comes from a recent study of NSSI in 509 male veterans with PTSD (Sacks, Flood, Dennis, Hertzberg, & Beckham, 2008), which found that 54.9% of the sample had engaged in some form of self-destructive behavior in the previous two weeks.

Other studies have noted the presence of NSSI in individuals diagnosed with dissociative disorders (69%; Briere & Gil, 1998; Zlotnick et al., 1996) and eating disorders (26-55%; Claes et al., 2001; Claes, Vandereycken, & Vertommen, 2003; Mitchell, Boutacoff, Hatsukami, Pyle, & Eckert, 1986; Paul, Schroeter, Dahme, & Nutzinger, 2002; Welch & Fairburn, 1996; Weiderman & Pryor, 1996a; Weiderman & Pryor, 1996b; Whitlock et al., 2006). The range of psychopathology associated with NSSI these studies found suggests much diagnostic heterogeneity among those who self-injure, yet there are few empirical studies assessing NSSI and other disorders. The ability to identify patterns of symptoms shared across disorders associated with NSSI could refine current knowledge about NSSI. Furthermore, examining the patterns of association between NSSI and a broader range of psychopathologies in a nonclinical college student sample would advance understanding by providing data on an under-studied population of self-injurers.

The aim of this study was to extend previous findings on psychopathological correlates of NSSI to a nonclinical sample of female college students. Because the larger study from which the current study was derived was exploratory, university women were selected as the target population because of evidence suggesting NSSI is more prevalent among women than men college students (e.g., Favazza, 1996; Gratz, 2001; Whitlock et al., 2006). This study represents an exploratory study of psychopathology symptoms in the NSSI population. Additionally, studies of psychological correlates of NSSI have utilized samples composed predominantly of women (e.g., Harned et al., 2006; Gratz, 2006; Polk & Liss, 2007). While diversification of samples is valuable, having a sample of only women in a small-scale study thus allows for ease of comparison with a large proportion of the NSSI literature and for the generalizability of results to this specific population. Nonetheless, we recognize the inherent limitation introduced by studying only females.

Based upon the literature, it was hypothesized that women with a history of NSSI would have significantly higher scores on measures of BPD, depression, anxiety, anxiety-related disorders, and pathology than those with no history of NSSI, and that their scale scores would show higher levels of general psychopathology. Because the study was exploratory, no hypotheses were proposed about potential differences in specific types of psychopathology among self-injuring groups.

METHOD

Participants

The sample was derived from the dataset of a larger study of NSSI in college women; it consisted of 34 participants who reported a lifetime history of NSSI and 32 who reported having never engaged in NSSI (control group). Participants were predominantly Caucasian (98.6%; n = 65), with the rest (1.4%; n = 1) being Native American. Participants ranged in age from 18 to 35 with a mean age of 19.4 years (SD = 2.2). Independent sample t-tests indicated that there were no significant differences in age, t (64) = 1.24;p = .218, between the NSSI group (M = 19.71 years; SD = 3.09 years) and the control group (M = 19.0 years; SD = 0.88 years). Although not statistically significant, Pearson chi square analyses of mental health treatment history using a 99% confidence interval revealed that a greater proportion ([chi square] =5.95; p =.015) of NSSI (29.4%; [CI.sub.99] = 9.2-49.5%) than control participants (6.3%; [CI.sub.99] = 4.8-17.3%) reported any history of treatment for psychological problems. This finding is consistent with the research on nonclinical populations of Whitlock and colleagues (2006), who found that only 53% of their self-injuring sample had ever been in therapy.

Procedure

Participants were recruited from a psychology department subject pool at a Midwestern university to participate in a larger study examining neuropsychological functioning in self-injuring women (Kerr, Johnson, Emerson, Brenna, Leer, Loe, et al., 2006). The data analyzed in the current study come from the larger protocol but address research questions not covered by the original project. All procedures used to recruit participants for the present study were used in the larger study. Potential participants were identified at the beginning of the academic year through a screening process approved by the Institutional Review Board of the University of North Dakota. Specifically, undergraduate students in psychology courses were given extra credit for voluntarily completing an instrument assessing lifetime and current NSSI (Deliberate Self-Harm Inventory; Gratz, 2001) to determine their eligibility to participate in the study. Participants who met the criteria based on a history of NSSI and who provided contact information for possible participation in additional studies were contacted by the first author in random order by telephone and invited to participate in the original study. Those contacted were informed that the study would "involve completing questionnaires about different feelings and behaviors." Power analyses run for the original study indicated a sample size of 60 participants (n = 30 per group) would be adequate (Kerr et al., 2006). Approximately 75% of those contacted agreed to participate.

As they arrived at the laboratory for the study, participants gave informed consent to the specific experiment. They then completed questionnaires assessing NSSI, psychopathology, and neurological functioning. The present study examines only the data related to measures of NSSI and psychopathology.

Measures

Personality Assessment Inventory (PAI; Morey, 1991). The PAI consists of 344 self-report items that assess different psychological disorders and personality traits. It contains 22 nonoverlapping scales, including 11 clinical scales with subscales examining different facets of each disorder. Items are answered on a four-point scale, and scores are obtained by summing item responses; higher scores indicate greater pathology. The PAI has demonstrated strong psychometric properties in clinical, nonclinical, and college student populations (Morey, 1991; Ruiz, Dickinson, & Pincus, 2002; Schinka, 1995a; Schinka, 1995b; Trull, 1995; Trull, Useda, Conforti, & Doan, 1997). Its reliability has been demonstrated by internal consistency alphas of 0.82 for college samples and 0.81 for normative samples (Morey). Morey reported a test-retest reliability of 0.83 across all test populations. For the current sample, the total scale alpha was 0.96. The PAI has also demonstrated validity through strong positive correlations with other widely used scales of psychopathology, such as the MMPI-2 (Morey, 1991).

Deliberate Self-Harm Inventory (DSHI; Gratz, 2001). The DSHI is a 17-item self-report inventory assessing a wide range of NSSI behaviors. Each item contains an initial yes/no question about a specific behavior (e.g., Have you ever intentionally cut your wrist, arms, or other area[s] of your body without intending to kill yourself?), followed by five follow-up questions about onset, number of episodes, time of last episode, length of time NSSI has been engaged in, and whether or not any NSSI episode has resulted in medical treatment. The DSHI is scored by summing the number of items to which the respondent answered yes.

Gratz (2001) reported a high degree of internal consistency ([alpha] = 0.83) and 2-to 4-week test-retest reliability of 0.68. There was also a high correlation between the number of NSSI behaviors endorsed by participants on the first and second administrations (r = 0.92). DSHI validity is supported by significant, moderate correlations with the self-harm items of the Diagnostic Interview for Borderlines-Revised (r = 0.43; Zanarini et al., 1989) and the Suicidal Behaviors Questionnaire (r = 0.35; Linehan, 1981 ). History of suicide attempts was correlated 0.20 and 0.21 with the dichotomous and frequency items of the DSHI, indicating that the DSHI measures a behavior distinct from suicide. Reliability analyses for the DSHI in the present study yielded a moderate value of [alpha] = 0.61.

Developmental History Questionnaire (DHQ; King, Bailly, & Moe, 2004). The DHQ is a 46-item self-report inventory that was used here to obtain demographic information. This instrument collects a broad range of information, such as data pertaining to age; education; relationship status; social support; religious beliefs; family structure (e.g., number of children, siblings, parents); and mental health issues (e.g., history of treatment; history of suicide attempts; history of gambling in the past year). Response formats are dichotomous, multiple choice, Likert, and free response. Although this instrument is essentially a demographic inventory, King et al. (2004) report that the data it collects correlate closely with those collected by other measures of developmental history.

RESULTS

Nonsuicidai Self-Injury

The forms of NSSI reported most frequently were cutting (58.8%), severe scratching (29.4%), skin carving (23.5%), and burning (17.7%). Overall, the majority of participants reported using one (55.9%) or two (29.4%) forms of NSSI, with 5.9% reporting three or four, and 2.9% five or more. The mean age of onset for the index episode was 15.02 years of age (SD = 1.3) with a range of 11 to 20. For all types of NSSI, frequency ranged from a single episode to over 100, with a majority (79.4%) of participants reporting at least two episodes. Only one reported that the self-harm (laceration) had required medical treatment. Responses to the DSHI item assessing the most recent NSSI episode indicated that 14.7% of NSSI participants reported an episode in the past month; 23.5% an episode within the last nine months; 29.4% an episode in the past year; and 35.3% an episode within the last two years.

Features of Psychopathology

A series of MANOVAs examined possible between-group differences on PAI clinical scales and subscales. To help control for Type I error, a p-value of .01 was adopted. An initial MANOVA covering all primary clinical scales of the PAl revealed that the overall model was significant, F (10, 52) = 4.66; p <.001. Follow-up analyses identified significant differences on seven clinical scales: Somatic Complaints, F(1,61) = 12.36; p =.001; Anxiety, F(1,61) = 19.21; p <.001; Anxiety-Related Disorders, F(1,61) = 12.99; p =.001; Depression, F(1,61) = 32.54; p<.001; Paranoia F(1,61) = 10.09; p =.002; Schizophrenia, F(1,61) = 15.94; p <.001; and Borderline Features, F(1,61) = 29.46; p <.001.

A subsequent MANOVA examined differences on the individual clinical subscales. Significant differences were identified among certain subscales of each general scale, indicating that symptom-specific psychopathology may better account for NSSI than global diagnostic categories (see Table 1). Independent-sample t-tests were conducted for the PAI Suicidality scale. Significant differences were noted, t (63) = 4.14; p <.001, with NSSI (M- 52.7; SD = 9.2) participants scoring significantly higher than controls (M = 44.9; SD = 5.3). Chi-square analyses of suicide-attempt history reported on the DHQ revealed no significant differences ([chi square] [1,66] = 2.88; p = .09) in the proportion of NSSI (20.6%; n = 7) and control (6.3%; n = 2) participants reporting suicide attempts; however, only NSSI participants (9.1%; n = 3) reported a history of two or more. Considering the few participants in the suicide attempt cells, this finding must be interpreted with caution.

Previous authors have argued strenuously for the use of predictive modeling as a post hoc procedure to clarify the results of an initial multivariate test (Cleophas, Zwinderman, Cleophas, & Cleophas, 2009). Thus, to further elucidate the nature of the significant differences in the original MANOVA, a post hoc stepwise logistic regression analysis was performed using NSSI group membership as the dependent variable and an alpha level of .05. All subscales from each clinical scale that was found to be significantly different in the original MANOVA were entered into the model in a separate block--all somatization subscales were entered in one block, all depression subscales in a separate block, and so forth. At each step, significant predictors within each group of subscales were entered into the model.

Goodness-of-fit was tested using the Hosmer-Lemeshow chi-square test. The final model indicated goodness-of-fit to the data was adequate ([chi square] [8,66] = 1.78; p = .98). An omnibus test revealed that the overall model was significant (([chi square] [1,66] = 24.47; p<.001 ). In total, four subscales yielded significant relationships with NSSI group membership and were entered into the model: Somatic Complaints, Affective Anxiety, Traumatic Stress, and Borderline Identity Problems. As can be seen from Table 2, when the Borderline Identity Problems subscale entered the model, all other predictors were no longer significant, indicating that this subscale demonstrated the strongest, though a modest, relationship with NSSI group membership when accounting for participants' levels of somatic complaints, traumatic stress, and affective anxiety.

DISCUSSION

Results from this study expand understanding of the psychopathological correlates of NSSI to a nonclinical sample of college women. As hypothesized, women with a history of NSSI had significantly higher levels of general psychopathology than controls. This finding is somewhat intuitive; individuals who engage in NSSI may be more likely to experience psychiatric distress than people who do not intentionally hurt themselves and may benefit from treatment regardless of the severity of their NSSI (Simeon & Favazza, 2001; Walsh, 2006). We found that women with NSSI scored significantly higher than controls on the PAI clinical scales for depression, borderline personality features, anxiety, suicidality, paranoia, and schizophrenia. The range of differences between women with and without NSSI reflects variations in functioning in domains of psychopathology that were not previously noted in college student samples.

Consistent with research using clinical samples of adults (e.g., Brown et al., 2002; Haw et al., 2002; Zanarini et al., 2003), women with NSSI were found to have elevated scores for depression and borderline features. Our findings also replicate the conclusions drawn by Andover et al. (2005) that borderline personality features may be important clinical correlates of NSSI in college students. Analyses of the PAI depression and BPD subscalcs provided additional detail about the pattern of symptoms that may be unique to NSSI. Women with NSSI scored significantly higher on the affective depression subscale and on the affective instability, identity problems, and negative relationships subscales of the BPD clinical scale. These results indicate that negative emotional lability, unstable relationships, and poor or distorted sense of identity may be a core symptom pattern that is associated with NSSI for at least one subset of individuals who engage in this behavior. The findings of the logistic regression analysis suggest that the self-concept of self-injurers may be a particularly unique risk factor for NSSI when accounting for anxiety and traumatic stress symptoms. These symptoms have also been identified within clinical samples of self-injurers (Brown et al., 2002; Nock & Prinstein, 2005), suggesting some consistency across different types of settings and samples.

Besides replicating previous findings, the current study extends the literature by noting that women with NSSI were also more likely to have elevated scores on anxiety, paranoia, and schizophrenia features. While previous studies with clinical samples have documented the presence of anxiety-based disorders among those with NSSI (e.g., Haw et al., 2001), no known studies have identified paranoia and schizophrenic features. Among college student samples, only anxiety has been acknowledged as possibly related to NSSI, often within the context of identifying how NSSI serves to alleviate anxiety feelings (Young et al., 2001). Thus, the current findings are unique and have potential to expand our understanding of the interplay between specific symptoms across multiple psychopathological domains and NSSI.

Our analysis of symptom patterns across forms of psychopathology on which participants with NSSI differed from controls revealed four themes: emotional distress, physical distress, cognitive distortion, and interpersonal difficulties. With regard to emotional distress, the NSSI group scored significantly higher than the control group on indices of affective pathology (ANX-A, DEP-A, BOR-A) and were more likely to report a history of traumatic stress (ARD-T). This pattern provides additional evidence that a range of aversive emotional states is associated with NSSI and that emotion dysregulation hypotheses about functional importance (e.g., Linehan, 1993; Nock & Prinstein, 2004) may be valid for both inpatient and nonpatient samples. To further elucidate the connection between these variables, additional research is needed to identify processes that precipitate the choice of NSSI as an emotion-regulating strategy.

Beyond affective disturbance, our results enhance current understandings of NSSI by finding that self-reported physiological symptoms differ between NSSI and controls. NSSI participants reported both significantly more physiological depressive and anxious symptoms and a preoccupation with physically distressing experiences within the body. One mechanism through which physiological distress may contribute to NSSI is by increasing bodily tension, which is often a marker of emotional distress. Increases in physical tension are believed to precipitate NSSI episodes (Chapman, Gratz, & Brown, 2006); our results support a biopsychosocial model of NSSI and point up the importance of incorporating biological and physiological mechanisms into etiological models of this behavior. Only a small handful of studies have examined the psychophysiology of individuals who engage in self-injury (Brain, Haines, & Williams, 1998; Haines, Williams, Brain, & Wilson, 1995). Recent research on physiological responses to stress in adolescent self-injurers (Nock and Mendes, 2008) found significantly higher levels of skin conductance (an established marker of physiological arousal) in the self-injury group than in control participants. Thus, our preliminary findings are consistent with other recent findings and underscore the importance of expanding research on NSSI to physiological correlates.

The results of this study extend but in some ways differ from previous findings. In addition to affective and physiological differences, we found higher degrees of certain problematic cognitive features across clinical scales. Women in the NSSI group reported more depressive cognition (DEP-C), disordered thoughts (SCZ-T), and hypervigilance (PAR-H; see Table 1). The NSSI group also had higher levels of identity problems (BOR-I), and this subscale had the strongest predictive relationship with NSSI in the post hoc logistic regression analysis. There are several possible explanations for this:

1. Examined together, these results may indicate that a distorted and negative view of the self or the world may be a clinically important characteristic of self-injurers. Although the effect of the identity problems subscale was modest (OR = 1.1; p = .02), this finding is unique and highlights a potentially fruitful direction for future research. It may also have useful implications for clinical work; for example, if this effect is found to be robust and consistent across samples, interventions with self-injurers might be tailored to focus more on such factors as self-related cognitions and self-concept.

2. The finding that self-injurers were more hypervigilant than controls suggests they may have more sensitivity to, or direct their attention to, potentially negative events or feedback. Hypervigilance and negatively valenced thought processes may perpetuate affective instability, increasing an individual's propensity for NSSI. This finding was consistent with the cognitive model of psychotic symptoms proposed by Beck, Rector, Stolar, and Grant (2009), which contends that psychotic symptoms, including disordered thoughts, originate from a transaction between an endogenous diathesis and an exogenous stressor. Beck and colleagues argue that the internal diathesis is comprised of both biological and cognitive vulnerabilities to stress, the latter consisting of a bias toward negative information and negativistic misinterpretation of events and stimuli, as well as attenuated cognitive resources. Thus, individuals with delusions or formal thought disorders may possess an "everyone-against-me" worldview and may be hypersensitive to negative information, especially about themselves. Integrating this model with the current findings, the higher scores on the hypervigilance subscale combined with higher scores on other cognition-related depression and schizophrenia subscales may indicate that cognitions related to the self might be targeted in treating NSSI. Recent discussions of effective treatment of NSSI emphasize modifying cognitive distortions as one component (Kerr, Muehlenkamp, & Turner, 2010; Muehlenkamp, 2006; Walsh, 2006). Our results indicate that maladaptive cognitions may be a potentially valuable target for assessment and treatment of NSSI. Replication of our findings is needed to validate the relationship between negative cognitions and NSSI.

Interpersonal difficulties was another theme emerging from our results. The fact that on the PAl NSSI participants reported experiencing significantly more negative relationships than controls points to the possibility that some features of interpersonal style may precipitate, or result from, NSSI. This is consistent with previous research in clinical samples (Chapman et al., 2006). A growing body of research suggests that many self-injurers, irrespective of diagnosis, experience interpersonal challenges they may not be equipped to manage effectively (Brown et al., 2002; Gratz, 2003; Linehan, 1993). While our findings are a start, additional research is needed to identify specific interpersonal characteristics that increase vulnerability to NSSI.

One noteworthy finding that warrants discussion was the significantly higher prevalence of suicidality among women with a history of NSSI. This finding was especially interesting when combined with the pattern of differences in psychopathology. These data are consistent with recent data from adolescent populations (Jacobson, Muehlenkamp Miller, & Turner, 2008; Nock, Joiner, Gordon, Lloyd-Richardson, & Prinstein, 2006; Muehlenkamp and Gutierrez, 2007; and Plener, Libal, Keller, Fegert, & Muehlenkamp, in press) suggesting that NSSI is a risk factor for suicidal behavior, especially for someone diagnosed with a mental illness.

Although the results of this study reflect the findings of just one empirical investigation, they have some implications for clinical practice. In applying the results to their practice, clinicians who work with clients who engage in NSSI might find the data useful for better conceptualizing this behavior in their clients, for several reasons:

1. The results reinforce the general importance of assessing the functions of NSSI (e.g., Lloyd-Richardson, Perrine, Dierker, & Kelly, 2007; Nock & Prinstein, 2004).

2. They also suggest that a detailed evaluation of cognitive processes, giving particular attention to cognitive distortions that may underlie NSSI, may be of value in assessing and treating clients who engage in it. Clearly, further research is needed to determine if people who self-injure are prone to specific patterns of dysfunctional cognitions that perpetuate or increase vulnerability to NSSI.

3. These findings, combined with data from other research (e.g., Nock & Mendes, 2008), underline the importance of paying close attention to the physical or physiological experiences that precede and follow a client's NSSI. Doing so may enhance the traditional "antecedent-behavior-consequence" model of behavioral assessment.

4. The findings also indicate the need to assess suicide risk in people who engage in or have a history of NSSI. While suicide attempts and NSSI are distinct behaviors, our data suggest there is a relationship between them. For instance, our finding that only NSSI participants reported multiple suicide attempts seems consistent with Joiner's model (2005) of suicidal behavior, which contends that repetition of self-harmful behavior (whether NSSI or failed suicide attempts) leads to habituation to self-inflicted injuries and thus increases the likelihood of suicide.

5. Finally, as suggested by previous authors (e.g., Gratz, 2007), the patterns of affective disturbance that emerged from this study suggest that interventions targeting emotional dysregulation, such as Dialectical Behavior Therapy (Linehan, 1993) as well as newer treatments (Gratz & Gunderson, 2006), may benefit self-injuring individuals (see also Kerr et al., in press, for a synthesis of NSSI intervention data).

Results from the current study suggest new ways to understand the psychopathology underlying NSSI in college women. However, the study has certain limitations. First, the data were derived from an archival dataset that was not originally designed to evaluate the current hypothesis, which limits both the type and number of analyses that can be conducted and the scope of the research questions. Also, the data were collected from a relatively specific and small sample. A priori power analyses indicated that a sample size of 60 would have enough power to detect any differences between groups. Indeed, the small effect sizes found in this study suggest two things: (a) this study had enough power to detect significant effects; and (b) the effects the study found may be robust. In this vein, it is important to highlight the small group effect sizes found (see Table 1). Though individually the effects may be small, in aggregate they may be more substantial. Research replicating our findings in larger college student samples is needed to strengthen confidence in our results.

Another possible limitation is that our sample consisted overwhelmingly of Caucasian women, which prevents us from generalizing the results to non-Caucasians and to males. Research with diverse samples that include male self-injurers will be crucial in determining whether similar psychopathology is associated with NSSI in other groups.

Another limitation of this research was that women comprising the NSSI group included those who were poly-episodic and those with single episodes. Because there may be differences between these subgroups of self-injurers, research is needed to determine if their levels and types of psychopathology differ. However, the heterogeneity of self-injurers in our sample may also be considered a strength, because those who engage in NSSI are heterogeneous in their clinical presentation.

Overall, the data from the current study suggest potentially important relationships between NSSI and numerous forms of affective, cognitive, physiological, and interpersonal disturbances that warrant further investigation. Combined with aggregated data from previous NSSI research, the current findings enhance our understanding of the range of psychopathology associated with NSSI and may help us refine causal models. Such models will hopefully provide valuable information for use in clinical practice.

Our findings also indicate that it may be productive for future study to identify features of psychopathology that share a common thread (e.g., affective instability, physiological symptomatology) rather than individual psychiatric disorders. Such an approach may make it possible to obtain a more complete picture of the psychological phenomena contributing to NSSI.

These data reflect both consistent and preliminary findings in that they echo the results of previous studies (e.g., on depression, anxiety, and BPD in NSSI) and extend them in new directions (e.g., thought disorder and psychosis features). Thus, it is incumbent to confirm and extend the current findings. Extending them to both a clinical sample of self-injurers and samples of people with current and repetitive NSSI may make it easier to understand the relationship between NSSI and psychopathology. The present study shed light on some cognitive features that may be related to NSSI that have not previously been explored. Thus, future research might be directed to identifying specific problematic cognitions that precipitate or perpetuate NSSI. Moreover, examination of specific affective symptoms associated with NSSI (e.g., as determined by clinical interviews) may be more valuable than the global pathology levels assessed by psychological symptom inventories like the PAI. Finally, as research documenting a broader array of psychopathology symptoms in self-injurers is amassed, it becomes increasingly important to identify the full spectrum of psychological disorders associated with NSSI--beyond BPD alone. Research that systematically examines the prevalence of NSSI in specific psychological disorders (e.g., bipolar, major depressive, and dissociative disorders) is critical; such investigations might enhance our understanding of the full etiology and epidemiology of NSSI.

Authors' Note: Parts of this manuscript were initially presented at the 3rd Annual Meeting of the International Society for the Study of Self-Injury, June 2008, in Boston, MA.

Acknowledgments: The authors wish to gratefully acknowledge the assistance of Tracey Emerson, Daniel Johnson, Tara Brenna, Kjellann Loe, Natalie Leer, Matthew Wall, and Alan King in the execution of this study. We also thank all reviewers for their feedback on earlier drafts.

REFERENCES

Andover, M. S., Pepper, C. M., Ryabchenko, K. A., Orrico, E. G., & Gibb, B. E. (2005). Self-mutilation and symptoms of depression, anxiety, and borderline personality disorder. Suicide and Life-Threatening Behavior, 35, 581-591.

Beck, A.T., Rector, N.A., Stolar, N., & Grant, P. (2009). Schizophrenia: Cognitive theory, research and therapy. New York: Guilford.

Brain, K.L., Haines, J., & Williams, C.L. 0998). The psychophysiology of self-mutilation: Evidence of tension reduction. Archives of Suicide Research, 4, 227-242.

Briere, J., & Gil, E. (1998). Self-mutilation in clinical and general population samples: Prevalence, correlates, and functions. American Journal of Orthopsychiatry, 68, 609-620.

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, 198-202.

Chapman, A.L., Gratz, K.L., & Brown, M.Z. (2006). Solving the puzzle of deliberate self-harm: The experiential avoidance model. Behaviour Research and Therapy, 44, 371-394.

Claes, L., Vandereycken, W., & Vertommen, H. (2001). Self-injurious behaviors in eating disorder patients. Eating Behavior, 2, 263-272.

Claes, L., Vandereycken, W., & Vertommen, H. (2003). Eating disordered patients with and without self-injurious behaviours: A comparison of psychopathological features. European Eating Disorders Review, 11, 379-396.

Cleophas, T.J., Zwinderman, A.H., Cleophas, T.F., & Cleophas, E.P. (2009). Post-hoc analyses in clinical trials, a case for logistic regression analysis. In T.J. Cleophas et al. (Eds.), Statistics applied to clinical trials, fourth edition, (pp. 229-234). Dordrecht, Netherlands: Springer.

Favazza, A.R. (1996). Bodies under siege: Self-mutilation and body modification in culture and psychiatry (2nd edition), London: Johns Hopkins.

Ferreira de Castro, E., Cunha, M., Pimenta, F., & Costa, I. 0998). Parasuicide and mental disorders. Acta Psychiatric Scandinavia, 97, 25-31.

Gratz, K.L. (2001). Measurement of deliberate serf-harm: Preliminary data on the Deliberate Self-Harm Inventory. Journal of Psychopathology and 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.

Gratz, K.L. (2006). Risk factors for deliberate self-harm among female college students: The role and interaction of childhood maltreatment, emotional inexpressivity, and affect intensity/reactivity. American Journal of Orthopsychiatry, 76, 238-250.

Gratz, K.L., Conrad, S., & Roemer, L. (2002). Risk factors for deliberate self-harm among college students. American Journal of Orthopsychiatry, 72, 128-140.

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.

Haines, J., Williams, C.L., Brain, K.L., & Wilson, G.V. (1995). The psychophysiology of self-mutilation. Journal of Abnormal Psychology, 104, 471-489.

Harned, M.S., Najavits, L. M., & Weiss, R. D. (2006). Self-harm and suicidal behavior in women with comorbid PTSD and substance dependence. American Journal on Addictions, 15, 392-395.

Haw, C., Hawton, K., Houston, K., &Townsend, E. (2001). Psychiatric and personality disorders in deliberate self harm patients. British Journal of Psychiatry, 70, 57-65.

Haw, C., Houston, K., Townsend, E., & Hawton, K. (2002). Deliberate self harm patients with depressive disorders: Treatment and outcome. Journal of Affective Disorders, 70, 57-65.

Hawton, K., Fagg, J., Simkin, S., Bale, E., & Bond, A. (1997). Trends in deliberate self-harm in Oxford, 1985-1995. Implications for clinical services and the prevention of suicide. British Journal of Psychiatry, 171, 556-560.

Jacobson, C.M., Muehlenkamp, J.J., Miller, A.L., & Turner, B. (2008). Psychiatric impairment among adolescents engaging in different types of deliberate self-harm. Journal of Clinical Child and Adolescent Psychology, 37, 363-375.

Joiner, T. (2005). Why people die by suicide. Cambridge, MA: Harvard University Press.

Kerr, P.L., Johnson, D., Emerson, Y., Brenna, T., Leer, N., Loe, K., Wall, M., & King, A.R. (May 2006). Executive functioning does not differ between self-harming and non-self-harming female university students. Poster presented at the 18th Annual Meeting of the Association for Psychological Science, New York, NY.

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.

King, A.R., BaiIly, M.D., & Moe, B.K. (2004). External validity considerations regarding college participant samples comprised substantially of psychology majors. In S.P. Shohov (Ed.). Advances in psychology research, Volume 29. Hauppauge, New York: Nova Science Publishers, Inc.

Klonsky, E.D., & Muehlenkamp, J.J. (2007). Self-injury: A research review for the practitioner. Journal of Clinical Psychology: In Session, 63, 1045-1056.

Klonsky, E.D., Oltmanns, T.F., & Turkheimer, E. (2003). Deliberate self-harm in a non-clinical population: Prevalence and psychological correlates. American Journal of Psychiatry, 160, 1501-1508.

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, 447-457.

Lieb, K., Zanarini, M. C., Schmahl, C., Linehan, M. M., & Bohus, P. M. (2004). Borderline personality disorder. Lancet, 364, 453-461.

Linehan, M.M. (1981). Suicidal behaviors questionnaire. Unpublished inventory, University of Washington, Seattle, Washington.

Linehan, M.M. (1993). Cognitive-behavioral treatment of borderline personality disorder. New York: The Guilford Press.

Lloyd-Richardson, 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.

Mitchell, J.E., Boutacoff, L.I., Hatsukami, D., Pyle, R.L., & Eckert, E.D. (1986). Laxative abuse as a variant of bulimia. Journal of Nervous and Mental Disease, 174, 174-176.

Morey, L.C. (1991). The Personality Assessment Inventory: Professional manual. Lutz, FL: Psychological Assessment Resources.

Muehlenkamp, J. J. (2005). Self-injurious behavior as a separate clinical syndrome. American Journal of Orthopsychiatry, 75, 1-10.

Muehlenkamp, J. J. (2006). Empirically supported treatments and general therapy guidelines for non-suicidal self-injury. Journal of Mental Health Counseling, 28, 166-185.

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, 69-82.

Nixon, M.K., Cloutier, M.A., & Aggarwal, S. (2002). Affect regulation and addictive aspects of repetitive self-injury in hospitalized adolescents. Journal of the American Academy of Child and Adolescent Psychiatry, 41, 1333-1341.

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.

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.

Nock, M. K. & Prinstein, M.J. (2004). A functional approach to the assessment of self-mutilative behavior. Journal of Consulting and Clinical Psychology, 72, 885-890.

Nock, M.K., & Prinstein, M.J. (2005). Contextual features and behavioral functions of self-mutilation among adolescents. Journal of Abnormal Psychology, 114, 140-146.

Paul, T., Schroeter, K., Dahme, B., & Nutzinger, D.O. (2002). Self-injurious behavior in women with eating disorders. The American Journal of Psychiatry, 159, 408-411.

Plener, P., Libal, G., Keller, F., Fegert, J.M., & Muehlenkamp, J. J. (in press). An international comparison of adolescent non-suicidal self-injury (NSSI) and suicide attempts: Germany and U.S. Psychological Medicine.

Polk, E., & Liss, M. (2007). Psychological characteristics of self-injurious behavior. Personality and Individual Differences, 43, 567-577.

Ross, S., & Heath, N. L. (2003). Two models of adolescent self-mutilation. Suicide and Life-Threatening Behavior, 33, 277-287.

Ruiz, M.A., Dickinson, K., & Pincus, A. (2002). Concurrent validity of the Personality Assessment Inventory Alcohol Problems (ALC) Scale in a college student sample. Assessment, 9, 261-270.

Sacks, M.B., Flood, A.M., Dennis, M.F., Hertzberg, D.A., & Beckham, J. (2008). Self-mutilative behaviors in male veterans with posttraumatic stress disorder. Journal of Psychiatric Research, 42, 487-494.

Schinka, J.A. (1995a). PAl profiles in alcohol-dependent patients. Journal of Personality Assessment, 65, 35-51.

Sehinka, J. A. (1995b). Personality Assessment Inventory scale characteristics and factor structure in the assessment of alcohol dependency. Journal of Personality Assessment, 64, 101-111.

Silverman, M. M., Berman, A. L., Sandal, N. D., O'Carroll, P. W., Joiner, T. E., Jr. (2007). Rebuilding the Tower of Babel: A revised nomenclature for the study of suicide and suicide behaviors. Part I. Background, rationale, and methodology. Suicide and Life-Threatening Behavior, 37, 248-263.

Simeon, D., & Favazza, A.R. (2001). Self-injurious behaviors: Phenomenology and assessment. In D. Simeon & E. Hollander (Eds.). Self-injurious behaviors: Assessment and treatment, Washington, D.C.: American Psychiatric Publishing.

Simeon, D., Stein, D., & Hollander, E. (1995). Depersonalization disorder and self-injurious behavior. Journal of Clinical Psychiatry, 56, 36-39.

Trull, T. J. (1995). Borderline personality disorder features in nonclinical young adults: I. Identification and validation. Psychological Assessment, 7, 33-41.

Trull, T. J., Useda, D., Conforti, K., & Doan, B. T. (1997). Borderline personality disorder features in nonclinical young adults: 2. Two-year outcome. Journal of Abnormal Psychology, 106, 307-314.

Walsh, B.W. (2006). Treating self-injury: A practical guide. New York: Guilford.

Welch, S.L., & Fairburn, C.G. (1996). lmpulsivity or comorbidity in bulimia nervosa: A controlled study of deliberate self-harm and alcohol misuse in a community sample. British Journal of Psychiatry, 169. 451-458.

Whitlock, J., Eckenrode, J., & Silverman, D. (2006). Self-injurious behaviors in a college population. Pediatrics, 117, 1939-1948.

Whitlock, J., Eels, G., Cummings, N., & Purington, A. (2007). Perceptions of changes in and causes of self-injurious behavior in college populations. Manuscript submitted for publication.

Weiderman, M.W. & Pryor, T. (1996a). Multi-impulsivity among women with bulimia nervosa. The International Journal of Eating Disorders, 20. 350-365.

Weiderman, M.W. & Pryor, T. (1996b). Substance use and impulsive behaviors among adolescents with eating disorders. Addictive Behaviors, 21, 269-272.

Wiederman, R.W., Sansone, R.A., & Sansone, L.A. (1999). Bodily self-harm and its relationship to childhood abuse among women in a primary care setting. Violence Against Women, 5, 155-163.

Young, R., VanBeinum, M., Sweeting, H., & West, P. (2007). Young people who self-harm. British Journal of Psychiatry, 191, 44-49.

Zanarini, M.C., Frankenburg, F.R., Hennen, J., & Silk, K.R. (2003). The longitudinal course of borderline psychopathology: 6-year prospective follow-up of the phenomenology of borderline personality disorder. American Journal of Psychiatry, 160, 274-283.

Zanarini, M.C., Gunderson, J.G., Frankenburg, F.R., & Chauncey, D.L. (1989). The revised diagnostic interview for borderlines: Discriminating BPD from other axis II disorders. Journal of Personality Disorders, 3, 10-18.

Zlotnick, C., Mattia, J.I., & Zimmerman, M. (2001). The relationship between posttraumatic stress disorder, childhood trauma and alexithymia in an outpatient sample. Journal of Traumatic Stress, 14, 177-188.

Zlotnick, C., Shea, M. T., Pearlstein, T., Simpson, E., Costello, E., & Begin, A. (1996). The relationship between dissociative symptoms, alexithymia, impulsivity, sexual abuse, and self-mutilation. Comprehensive Psychiatry, 37, 12-16.

Patrick L. Kerr is affiliated with the West Virginia University School of Medicine Department of Behavioral Medicine and Psvchiatry-Charleston Division. Jennifer J. Muehlenkamp is affiliated with the University of Wisconsin-Eau Claire Department of Psychology. Correspondence concerning this article should be directed to Patrick L. Kerr, 3200 MacCorkle Ave SE, Charleston, WV 25304. E-mail: PatrickLKerr@gmail.com.
Table 1. Results of MANOVA Clinical Subscale T-Score Comparisons

Dependent Variable NSSI Control F p [[eta].
 (SD) (SD) sup.2]

Somatic Complaints
 Conversion 50.69 45.87 4.16 .045
 (12.31) (5.12)
 Somatization 53.88 46.44 14.20 .000 *** 0.19
 (9.62) (5.66)
 Health concerns 55.94 48.56 7.40 .008 * 0.11
 (13.65) (6.98)

Anxiety
 Cognitive 54.17 45.84 7.22 .009 * 0.10
 (13.29) (11.38)
 Affective 52.31 44.28 16.91 .000 *** 0.21
 (9.64) (5.40)
 Physiological 55.21 45.25 16.90 .000 *** 0.21
 (11.12) (8.03)

Anxiety-Related Disorders
 Obsessive-compulsive 54.28 50.12 2.24 .140
 (12.38) (9.68)
 Phobic avoidance 53.03 46.63 5.78 .019
 (12.04) (9.07)
 Traumatic stress 55.09 45.22 16.49 .000 *** 0.21
 (12.27) (6.21)

Depression
 Cognitive 54.09 44.41 15.63 .000 *** 0.20
 (11.45) (7.81)
 Affective 52.81 43.34 20.87 .000 *** 0.25
 (10.42) (5.37)
 Physiological 58.56 46.47 21.18 .000 0.26
 (11.94) (8.85)
Paranoia
 Hypervigilance 51.09 42.66 13.90 .000 *** 0.18
 (9.44) (8.65)
 Persecution 48.06 45.19 2.72 .104
 (7.44) (6.48)
 Resentment 49.66 44.22 4.76 .033
 (10.96) (8.88)
Schizophrenia
 Psychotic experiences 47.47 42.84 7.58 .008 * 0.11
 (7.75) (5.49)
 Social detachment 49.37 44.91 5.49 .022
 (8.88) (6.12)
 Thought disorder 53.12 43.87 16.95 .000 *** 0.22
 (11.45) (5.51)v
Borderline Features
 Affective instability 49.94 41.69 14.82 .000 *** 0.19
 (9.60) (7.40)
 Identity problems 52.94 40.94 28.84 .000 *** 0.32
 (9.84) (7.94)
 Negative relationships 52.72 40.94 11.85 .001 ** 0.16
 (9.71) (9.46)
 Self-harm 50.31 44.12 9.37 .003 * 0.13
 (8.70) -7.41

Note: NSSI = Nonsuicidal self-injury group; * p [less than or
equal to] .01; ** p [less than or equal to] .001.

Table 2. Logistic Regression for Prediction of NSSI Group Membership

 Wald
Predictor B [chi square] p OR [Cl.sub.95]

Somatic complaints 0.08 1.64 0.20 1.08 .96-1.21
Affective anxiety 0.05 1.10 0.29 1.06 .95-1.17
Traumatic stress 0.03 0.39 0.54 1.03 .94-1.13
Identity problems 0.11 5.44 0.02 1.12 1.02-1.23
COPYRIGHT 2010 American Mental Health Counselors Association
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 2010 Gale, Cengage Learning. All rights reserved.

Article Details
Printer friendly Cite/link Email Feedback
Author:Kerr, Patrick L.; Muehlenkamp, Jennifer J.
Publication:Journal of Mental Health Counseling
Date:Oct 1, 2010
Words:7669
Previous Article:Introduction to the special section on Nonsuicidal Self-Injury (NSSI).
Next Article:Self-reported experience of self-injurious behavior in college students.
Topics:

Terms of use | Privacy policy | Copyright © 2019 Farlex, Inc. | Feedback | For webmasters