Clinical assessment of non-suicidal self-injury: A systematic review of instruments

What methods are used in research of firsthand experiences with online self-harming and suicidal behavior? A scoping review

BACKGROUND

Online self-harming and suicidal behavior is a novel and rapidly increasing phenomenon warranting comprehensive mapping of used research methods.

AIM

To identify and map how knowledge on online self-harming and suicidal behavior is gathered, including how data are collected e.g. questionnaires and interviews.

METHODS

The review follows the Joanna Briggs Institute Manual for Scoping Reviews in tandem with Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. A keyword search of three electronic databases was conducted on two occasions, yielding 5422 records. Following duplicate removal, the records were screened based on the following inclusion criterions; (1) in English or Nordic language and published between 2011-2022, (2) presenting results for self-harming and/or suicidal behavior on social media and (3) using tools for either interview or questionnaire aiming at assessment of the experience of online self-harming and suicidal behavior from the perspective of the person who engages in the behavior. A total of 64 articles were included.

RESULTS

45 used questionnaires, 17 used interviews, and two studies mixed the two approaches. 17% of the studies had made some effort to ensure validity within the questionnaires and 15.8% gave full access to the interview guide.

CONCLUSION

Research into online self-harming and suicidal behavior is characterized by a lack of validated measurements and methodological transparency. The results emphasize a need for further development, testing, and validation of questionnaires and greater openness and reflexivity in qualitative methodology to enable cross-study comparison and advance knowledge of this complex phenomenon.

Emotional dysregulation and its pathways to suicidality in a community-based sample of adolescents

OBJECTIVE

Effective suicide prevention for adolescents is urgently needed but difficult, as suicide models lack a focus on age-specific influencing factors such as emotional dysregulation. Moreover, examined predictors often do not specifically consider the contribution to the severity of suicidality. To determine which adolescents are at high risk of more severe suicidality, we examined the association between emotional dysregulation and severity of suicidality directly as well as indirectly via depressiveness and nonsuicidal self-injury.

METHOD

Adolescents from 18 high schools in Bavaria were included in this cross-sectional and questionnaire-based study as part of a larger prevention study. Data were collected between November 2021 and March 2022 and were analyzed from January 2023 to April 2023. Students in the 6th or 7th grade of high school (11-14 years) were eligible to participate. A total of 2350 adolescents were surveyed and data from 2117 students were used for the analyses after excluding incomplete data sets. Our main outcome variable was severity of suicidality (Paykel Suicide Scale, PSS). Additionally, we assessed emotional dysregulation (Difficulties in Emotion Regulation Scale, DERS-SF), depressiveness (Patient Health Questionnaire, PHQ-9) and nonsuicidal self-injury (Deliberate Self-Harm Inventory, DSHI).

RESULTS

In total, 2117 adolescents (51.6% female; mean age, 12.31 years [standard deviation: 0.67]) were included in the structural equation model (SEM). Due to a clear gender-specific influence, the model was calculated separately for male and female adolescents. For male adolescents, there was a significant indirect association between emotional dysregulation and severity of suicidality, mediated by depressiveness (β = 0.15, SE = .03, p = .008). For female adolescents, there was a significant direct path from emotional dysregulation to severity of suicidality and also indirect paths via depressiveness (β = 0.12, SE = .05, p = 0.02) and NSSI (β = 0.18, SE = .04, p < .001).

CONCLUSIONS

Our results suggest that gender-related risk markers in 11-14-year-olds need to be included in future suicide models to increase their predictive power. According to our findings, early detection and prevention interventions based on emotion regulation skills might be enhanced by including gender-specific adjustments for the co-occurrence of emotional dysregulation, depressiveness, and nonsuicidal self-injury in girls and the co-occurrence of emotional dysregulation and depressiveness in boys.

Functions of nonsuicidal self-injurious behavior in Russian patients with suicidal ideation

Introduction

Nonsuicidal self-injurious behavior (NSSI) is an important risk factor for future suicide attempts. Previous research has identified a number of motivations for engaging in NSSI. The aim of the present study was to translate the Inventory of Statements About Self-Injury (ISAS) into Russian and then to evaluate its psychometric properties in a sample of patients with non-psychotic mental disorders and suicidal ideation (SI). Other aims were to determine the prevalence of specific NSSI functions in this population and to assess the relationship between different NSSI functions and clinical and psychological parameters.

Participants and methods

The study was conducted at the largest center for non-psychotic mental disorders in Moscow. All admitted patients with both NSSI and SI completed the Russian version of the ISAS-II, underwent the Self-Injurious Thoughts and Behaviors Interview, and completed the Personality Inventory for DSM-5 and ICD-11 Brief Form Plus-Modified, the Beck Depression Inventory, and the State-Trait Anxiety Inventory.

Results

A total of 614 patients were included in the study. 543 (88.4%) patients were assigned female at birth with a mean age of 24.86 (7.86) years. Factor analysis supported a two-factor structure (Intrapersonal and Interpersonal) of the Russian version of the ISAS-II, but in contrast to the original study, the "Marking distress" function loaded more strongly on the Interpersonal factor. In people with non-psychotic mental disorders and SI, Interpersonal functions of NSSI are associated with more severe depressive symptoms (r = 0.34), 12 months history of NSSI (r = 0.30), higher number of NSSI methods (r = 0.41), likelihood of future NSSI (r = 0.35) and psychoticism (r = 0.32).

Conclusion

The Russian version of the ISAS-II is a valid and reliable instrument for assessing NSSI functions in a population at high risk for suicide attempts. Interpersonal functions are associated with a number of unpleasant clinical and psychological features.

Longitudinal Associations Between Nonsuicidal Self-Injury, Depressive Symptoms, Hopelessness, and Emotional Dysregulation in Adolescents

Nonsuicidal self-injury (NSSI) in adolescents has been associated with increased depressive symptomatology, hopelessness, and emotional dysregulation; however, few studies have examined longitudinal associations between NSSI and these problems. This study examines the longitudinal relationships among these variables in community adolescents and whether the pattern of relationships varies between boys and girls. The participants were 785 adolescents (57.1% girls) aged 13 to 18 years (M = 15.64; SD = 1.08) who completed self-reported measures of NSSI, depression, hopelessness, and emotional dysregulation at least once at two moments separated by 1 year. The longitudinal model was tested through structural equation modeling and multiple group analysis. NSSI predicted increased depressive symptoms, hopelessness, and emotional dysregulation; depressive symptoms predicted NSSI; hopelessness predicted depressive symptoms; and emotional dysregulation predicted depressive symptoms and hopelessness. The pattern was similar for girls and boys, although girls scored higher on all variables. The results underscore the important bidirectional associations between NSSI and other risk factors throughout adolescence. These findings will support prevention and interventions for NSSI and internalizing symptoms in adolescents in school and clinical settings.

Implicit cognitions on self-injurious and suicidal behavior in borderline personality disorder

BACKGROUND AND OBJECTIVES

Performance on implicit measures of suicidality has been associated with suicidal and nonsuicidal self-injury. Despite the high prevalence of self-harm in patients with borderline personality disorder (BPD), no previous study has assessed implicit measures in this patient group.

METHODS

Forty patients with BPD and 25 healthy controls completed three implicit association tests (IATs) (Death words - Me/Others words, Self-Harm pictures - Me/Others, and Self-Harm pictures - Good/Bad words) and a subliminal priming task (effect of the primes "dying"/"growing" on the categorization speed of positive/negative adjectives) as well as measures of psychopathology (suicidal ideation, previous nonsuicidal self-injury, borderline symptomatology, depression, and hopelessness).

RESULTS

Patients with BPD had higher scores on all three IATs than healthy controls. The subliminal priming procedure did not reveal group differences. Correlations between implicit measures and psychopathology among patients with BPD were mostly weak and nonsignificant with a few exceptions: Positive correlations were observed between IAT Self-Harm - Good/Bad and lifetime frequency of nonsuicidal self-injury, between IAT Self-Harm - Me/Others and depression, and between IAT Death - Me/Others and depression. Correlations between implicit measures were weak to moderate.

LIMITATIONS

The study was cross-sectional only, and the study had reduced power as the sample size was limited.

CONCLUSIONS

As expected, patients with BPD had higher scores than healthy controls on the IATs, which indicates higher implicit self-identification with self-harm and death as well as stronger implicit positive attitudes towards self-harm. The mostly weak correlations between implicit and explicit measures speak against the discriminative value of IATs in patients with BPD.

Associations Between Family Function and Non-suicidal Self-injury Among Chinese Urban Adolescents with and Without Parental Migration

The study aims to explore the effect of family function on non-suicidal self-injury (NSSI) among Chinese urban adolescents with and without parental migration. Between April 21st to May 12th, 2021, adolescents were recruited from Shenzhen city of Guangdong province, China (n = 124,357). Of all the participants, 22,855 (18.4%) were left-behind children (LBC). Family function, NSSI, depression, and socio-demographic characteristics were assessed using a series of self-reported questionnaires. Urban LBC had a higher NSSI frequency, while a lower level of family function than non-LBC. After controlling for confounders, parental migration was significantly associated with NSSI, and family dysfunction was a robust risk factor for NSSI as well. The protective effect of family function on NSSI of LBC was stronger than non-LBC. This implies that children with higher levels of family function tend to exhibit a lower frequency of NSSI, especially in those with parental migration. In practice, adolescents' NSSI prevention and intervention strategies should focus on improving family function.

Botulinum Neurotoxin Injections in Children with Self-Injurious Behaviors

Self-injurious behaviors are repetitive, persistent actions directed toward one's body that threaten or cause physical harm. These behaviors are seen within a broad spectrum of neurodevelopmental and neuropsychiatric conditions, often associated with intellectual disability. Injuries can be severe and distressing to patients and caregivers. Furthermore, injuries can be life-threatening. Often, these behaviors are challenging to treat and require a tiered, multimodal approach which may include mechanical/physical restraints, behavioral therapy, pharmacotherapy, or in some cases, surgical management, such as tooth extraction or deep brain stimulation. Here, we describe a series of 17 children who presented to our institution with self-injurious behaviors in whom botulinum neurotoxin injections were found helpful in preventing or lessening self-injury.

Non-suicidal self-injury: A bibliometrics study and visualization analysis from 2002 to 2022

OBJECTIVE

To overview the research actuality and offer the hotspots and cutting-edge issues in the field of Non-suicidal Self-injury (NSSI) by using bibliometric analysis.

MATERIALS AND METHODS

Publications related to NSSI from 2002 to 2022 were extracted from the Web of Science Core Collection (WoSCC) database. CiteSpace V 6.1.R2 and VOSviewer 1.6.18 were used to visually analyzed institutions, countries, journals, authors, references, and keywords in research on NSSI.

RESULTS

A total of 799 studies about NSSI were analyzed via CiteSpace and VOSviewer. The number of annual publications related to NSSI is fluctuating growth. The USA and Harvard University are the most productive country and institutions. In the case of journals and co-cited journals, Psychiatry Research are the most productive journal and also ranked highest among co-cited journals. Furthermore, Michael Kaess has published the most publications, and Matthew K. Nock is the most cited author. An article published by Swannell SV et al. shows the highest citation counts. After analysis, the most common keywords are harm, adolescents and prevalence. The gender difference, diagnosis, and dysregulation are frontier areas of NSSI research.

CONCLUSION

This study analyzed the research of NSSI from multiple perspectives, and provides valuable information for researchers to capture the current status, hot spots, and frontier trends of NSSI.

Peripheral and neural correlates of self-harm in children and adolescents: a scoping review

BACKGROUND

Self-harm in children and adolescents is difficult to treat. Peripheral and neural correlates of self-harm could lead to biomarkers to guide precision care. We therefore conducted a scoping review of research on peripheral and neural correlates of self-harm in this age group.

METHODS

PubMed and Embase databases were searched from January 1980-May 2020, seeking English language peer-reviewed studies about peripheral and neural correlates of self-harm, defined as completed suicide, suicide attempts, suicidal ideation, or non-suicidal self-injury (NSSI) in subjects, birth to 19 years of age. Studies were excluded if only investigating self-harm in persons with intellectual or developmental disability syndromes. A blinded multi-stage assessment process by pairs of co-authors selected final studies for review. Risk of bias estimates were done on final studies.

RESULTS

We screened 5537 unduplicated abstracts, leading to the identification of 79 eligible studies in 76 papers. Of these, 48 investigated peripheral correlates and 31 examined neural correlates. Suicidality was the focus in 2/3 of the studies, with NSSI and any type of self-harm (subjects recruited with suicidality, NSSI, or both) investigated in the remaining studies. All studies used observational designs (primarily case-control), most used convenience samples of adolescent patients which were predominately female and half of which were recruited based on a disorder. Over a quarter of the specific correlates were investigated with only one study. Inter-study agreement on findings from specific correlates with more than one study was often low. Estimates of Good for risk of bias were assigned to 37% of the studies and the majority were rated as Fair.

CONCLUSIONS

Research on peripheral and neural correlates of self-harm is not sufficiently mature to identify potential biomarkers. Conflicting findings were reported for many of the correlates studied. Methodological problems may have produced biased findings and results are mainly generalizable to patients and girls. We provide recommendations to improve future peripheral and neural correlate research in children and adolescents, ages 3-19 years, with self-harm.

Lifetime prevalence and clinical correlates of nonsuicidal self-injury in youth inpatients with eating disorders: a retrospective chart review

BACKGROUND

Youths with eating disorders (EDs) engaging in nonsuicidal self-injury (NSSI) are at higher suicide risk because EDs and NSSI are associated with suicidality. However, epidemiologic data on NSSI lacks in the vulnerable group of youth ED inpatients.

METHODS

This retrospective chart review included patients up to 18 years of age with an ICD-10 diagnosis of anorexia nervosa, restricting type (AN-R), anorexia nervosa, binge-purge type (AN-BP), and bulimia nervosa (BN), treated at the child and adolescent inpatient department of the University Hospital in Berlin, Germany, between 1990 and 2015. Across and within ED subgroups, lifetime NSSI prevalence, methods of self-harm, and clinical correlates were evaluated. Independent correlations of demographic and clinical factors with NSSI were identified via multivariable regression models.

RESULTS

Of 382 inpatients (median = 15.6 (range = 9-18) years, females = 97.1%), 21.5% reported lifetime NSSI, consisting of cutting = 86.6%, scratching = 12.2%, and hitting = 8.5%. NSSI was more frequent in BN (47.6%) and AN-BP (39.3%) than AN-R (8.3%) (Φ = 0.43). Across ED subgroups, NSSI was associated with a higher prevalence of psychiatric comorbidities (AN-R: Φ = 0.55; AN-BP: Φ = 0.69; BN: Φ = 0.78), suicidal ideation (AN-R: Φ = 0.30; AN-BP: Φ = 0.38; BN: Φ = 0.29), and psychiatric medication use (AN-R: Φ = 0.23; AN-BP: Φ = 0.64; BN: Φ = 0.60). In multivariable regression analyses, NSSI was independently associated with a higher prevalence of psychiatric comorbidities (AN-R: OR = 2.93 [1.42, 6.04]; AN-BP: OR = 2.67 [1.13, 6.31]; BN: OR = 3.75 [1.71, 8.23]). Additionally, independent correlates with NSSI in AN-R included a higher prevalence of suicidal ideation (OR = 0.21 [0.72, 0.64]) and less weekly weight gain (OR = 0.03 [0.02, 0.43]), while in BN, NSSI was correlated with longer inpatient treatment duration (OR = 1.01 [1.00, 1.02]).

CONCLUSIONS

There is a high lifetime prevalence of NSSI among youth with AN and BN requiring inpatient treatment, especially those with binge-purge behaviors. Treatment programs must be tailored to address psychiatric comorbidities and suicidality to improve patient care and suicide prevention.

TRIAL REGISTRATION

This study was not considered a clinical trial but a retrospective chart review based on routinely assessed clinical parameters. The study includes data from human participants, however: (1) no intervention and no prospective assignment to interventions were performed, and (2) no evaluation of an intervention on participants was accomplished.