An experimental investigation of emotional willingness and physical pain tolerance in deliberate self-harm: the moderating role of interpersonal distress

Emotion dysregulation in nonsuicidal self-injury: Dissociations between global self-reports and real-time responses to emotional challenge

INTRODUCTION

Prominent theories of nonsuicidal self-injury (NSSI) propose that the behaviour is characterised by amplified emotional responses. However, little is known about how people who self-injure respond during emotional challenge.

METHODS

We measured subjective and physiological responding (heart rate, heart rate variability, and electrodermal responding) among young adults with past-year NSSI (n = 51) and those with no lifetime NSSI (n = 50) during a resting baseline, a stress induction, and a post-stress resting phase. Participants reported the extent to which they spontaneously used cognitive reappraisal and expressive suppression during the post-stress phase. Two weeks later, a subset of the sample (n = 42) reported how they remembered feeling during the laboratory session.

RESULTS

Although the NSSI group reported considerably greater emotion dysregulation than Controls, both groups showed similar subjective and psychological reactivity to, and recovery from, emotional challenge. Both groups used reappraisal and suppression regulation strategies following acute stress to a similar extent, and later came to remember the emotional challenge in a similar manner.

LIMITATIONS

Within the NSSI group, past-year self-injury tended to be infrequent and sporadic. Only 43.6% of the sample participated in the follow-up survey assessing memory of emotional challenge.

CONCLUSIONS

Findings demonstrate that the role of emotion in NSSI is more complex than prominent theories can account for, raising substantial questions regarding the nature of emotion in NSSI. A more comprehensive understanding of the role of emotion in NSSI is needed to inform intervention strategies to better support people who self-injure.

Social stressors, emotional responses, and NSSI urges and behaviors in daily life

BACKGROUND

The defective self model of nonsuicidal self-injury (NSSI) theorizes that individuals who are highly self-critical are more likely to choose NSSI to regulate emotions. This model indirectly suggests that individuals who engage in NSSI may experience more self-conscious emotions in response to negative social feedback, increasing risk for near-term NSSI. This study examined (1) whether individuals with a history of NSSI (vs. without) display greater self-conscious and negative emotional reactions to daily social stressors, and more problematic features of these daily social stressors, and (2) whether greater-than-usual negative emotional reactions and social stressor features predict NSSI urges and behaviors in daily life.

METHODS

Participants were 134 female college students with recent, recurrent NSSI (n = 77) or no NSSI history (n = 57). Participants completed baseline measures of socioemotional functioning and a two-week daily diary protocol.

RESULTS

The NSSI (vs. no NSSI) group reported significantly greater self-conscious and negative emotional reactions to daily social stressors, and social stressors characterized by greater dysfunction. In the NSSI group, experiencing social stressors characterized by greater distress than one's average during the daily diary period was associated with same-day NSSI urges and behavior, greater confusion than one's average predicted same-day NSSI urges, and greater conflict than one's average predicted same-day NSSI behavior. Greater self-conscious and negative emotional reactions to these stressors than one's average predicted same-day NSSI urges and behavior.

LIMITATIONS

Limitations include reliance on self-report, a once-daily assessment, and lack of generalizability to other samples.

CONCLUSIONS

Interpersonal conflict and increased self-conscious emotions pose vulnerability for NSSI. Prevention and intervention efforts would benefit from including a focus on interpersonal functioning.

Heterogeneity of non-suicidal self-injury behavior in adolescents with depression: latent class analysis

BACKGROUND

Non-suicidal self-injury (NSSI) by adolescent patients with depression has become a serious public health problem. This cross-sectional study aims to identify subgroups of adolescents based on NSSI and explore the factors related to these subgroups.

METHODS

The study recruited 326 in- and out-patient adolescents (263 girls and 63 boys) aged 12 to 18 years (mean = 14.7, SD = 1.6) who had self-injured in the past year. Latent class indicators included 12 NSSI variables, as well as suicidal ideation. Logistic regression examined associations between identified classes and related factors.

RESULTS

In this study, two distinct subgroups were identified: a "high suicidal ideation NSSI group" (n = 129, 39.6%) and a "low suicidal ideation NSSI group" (n = 197, 60.4%). Depression (OR = 1.10; 95% CI, 1.05-1.16), female (OR = 2.01; 95% CI, 1.09-3.69), left-behind experience (OR = 2.08; 95% CI, 1.17-3.71), single-parent family (OR = 1.84; 95% CI, 1.11-3.04) and peer victimization (OR = 1.04; 95% CI, 1.02-1.05) increases the probability of belonging to the "high suicidal ideation NSSI group". A high level of perceived social support (OR = 0.99; 95% CI, 0.97-0.99) was a protective factor towards NSSI.

CONCLUSIONS

This study identifies two subgroups of NSSI and the factors associated with each subgroup. The early identification of high-risk groups for major NSSI in adolescents diagnosed with depression is possible due to the identification of correlating factors. Different treatment plans can be developed for different subtypes of NSSI to improve the effectiveness of prevention and intervention, promoting the healthy physical and mental development of adolescents with depression.

Emotional responding to overt and subtle social exclusion among young women who engage in non-suicidal self-injury

People who engage in non-suicidal self-injury (NSSI) consistently report greater emotion reactivity and dysregulation than their peers. However, evidence that these self-reports reflect an amplified emotional response under controlled conditions is limited. Here we test the effects of both subtle and overt social exclusion, to determine whether self-reported emotion dysregulation reflects responses to real-time emotional challenge for people who self-injure. We recruited 100 young women with past-year NSSI and 100 without NSSI to an online experiment. Participants took part in a baseline social inclusion ball-tossing game, followed by either an overt or subtle social exclusion ball-tossing game, while we measured negative mood and belongingness. Despite reporting greater emotion reactivity (d = 1.40) and dysregulation (d = 1.63) than controls, women with past-year NSSI showed no differences in negative mood or belongingness ratings in response to either overt or subtle social exclusion. Within the NSSI group, exploratory analyses found greater endorsement of intrapersonal functions predicted greater negative mood following social exclusion (β = 0.19). Given that amplified emotional responding is central to prominent theoretical models of NSSI, findings highlight the need to better understand the divergence in findings between self-reported emotion dysregulation and real-time emotional responding among people who self-injure.

A network analysis on self-harming and problematic smartphone use - The role of self-control, internalizing and externalizing problems in a sample of self-harming adolescents

BACKGROUND

Research has shown an increased risk for Non-suicidal self-injurious (NSSI) behavior as well as Problematic Smartphone Use (PSU) and particularly in adolescence, a developmental period defined by multi-level changes and still poor self-control capacities associating with risk-taking behaviors.

OBJECTIVE

The current study was aimed to assess the pattern of mutual relations characterizing NSSI considering self-control, internalizing and externalizing problems, and investigating how PSU fits within the network since NSSI and PSU are here conceptualized as attempts at emotion regulation. Age and gender differences were also assessed.

METHOD

Participants were Italian adolescents presenting NSSI behavior (N = 155; Mage = 14.68; SD = 1.647; Range = 11-18; 43.2%-females); the sample is based on community recruitment. A Network Analysis was performed to assess the organizational structure of NSSI; age and gender differences were assessed through multivariate rank tests further applying multiplicity control.

RESULTS

The emerged Network showed the centrality of low self-control and internalizing problems for NSSI. NSSI and PSU were associated through low self-control, and so were PSU and externalizing problems. Significant age differences were observed showing a decrease in NSSI as age increases (stat = -2.86; adj.p = .029). No gender differences have emerged.

CONCLUSIONS

The current findings provide support for the consideration and investigation of PSU as regards NSSI behavior in adolescence. Moreover, these findings point to the relevance of prevention practices during this peculiar developmental period, particularly sustaining self-control capacities and the use of more adaptive emotion regulation strategies, thereby limiting the accrue of at-risk behaviors.

An experimental examination of interpersonal problem-solving in nonsuicidal self-injury: A pilot study

Nonsuicidal self-injury (NSSI) typically occurs in the presence of negative emotions. Prior research has emphasized interpersonal stress as a specific context that may elevate negative emotions in this population and even increase the likelihood of NSSI behavior. However, the factors that contribute to the relationship between interpersonal stress and NSSI have received relatively limited attention. The current pilot study aimed to experimentally examine interpersonal problem-solving as a potential moderator of the interpersonal stress - NSSI risk relationship among those with a NSSI history. Eighty-six participants (52.3% with NSSI history) were randomly assigned to one of three mood induction conditions (interpersonal negative, general negative, interpersonal neutral), after which they completed an interpersonal problem-solving task and a laboratory analogue of self-injurious behavior. Results indicated that NSSI history was associated with poorer interpersonal effectiveness. Further, individuals with a history of NSSI who experienced an interpersonally-focused negative mood and produced less effective interpersonal solutions were more self-harming on a laboratory analogue of self-injurious behavior. While the present findings are preliminary in nature, they offer guidance for research moving forward and, if replicated, suggest interpersonal problem-solving as a potential treatment target among individuals engaging in NSSI.

Associations between non-suicidal self-injury and negative romantic relationship life events in male justice-involved adolescents

BACKGROUND

In the current study we investigated impulsivity and negative life events in relation to non-suicidal self-injury (NSSI) in correctional settings.

METHODS

A total of 141 male justice-involved juveniles participated in our cross-sectional study, aged between 14 and 21 years old (M = 17.75; SD = 1.38). Data collection took place in correctional institutions in Hungary. A binary logistic regression was conducted to investigate possible associations between NSSI, impulsivity and negative life events.

RESULTS

Lifetime prevalence of NSSI was 53.9% (N = 76). In a binary logistic regression model, only negative romantic relationship events were significantly associated with the risk of current NSSI (OR = 1.29; 95% CI = [1.06-1.56]). Other types of negative life events (family-related, friendship-related), impulsivity, age and conviction status did not have a significant role in the model.

CONCLUSIONS

The results suggest that juvenile offenders should receive additional support to manage stress that is associated with negative life events, especially problems in romantic relationships. It is essential to help young inmates to find an adaptive way of reducing stress caused by negative relationship life events.

Testing Whether Suicide Capability Has a Dynamic Propensity: The Role of Affect and Arousal on Momentary Fluctuations in Suicide Capability

To prevent suicidal behaviors, it is crucial to understand the mechanisms and processes that enable an individual to act on suicidal thoughts. Suicide capability, which involves an increased pain tolerance and fearlessness of death, is a critical factor that enables an individual to endure the physical pain necessary to make a lethal suicide attempt. Extant research has largely conceptualized suicide capability as developing linearly in response to painful and provocative experiences, but the emerging literature on the temporal dynamics of suicide has been challenging the notion of linearity in suicide risk. Few studies have directly measured and compared changes in suicide capability in response to rumination on different affective states. We sought to experimentally test if rumination in the context of low vs. high arousal emotions will prompt distinct changes in two core components of suicide capability: pain tolerance and fearlessness of death on two undergraduate student samples. In both studies, participants provided measures of subjective emotional state as well as pain threshold, tolerance, and persistence before and after completing experimental manipulations which included both emotion and rumination induction procedures. In the second study, measures of fearlessness about death and physiological arousal (heart rate) were added to the experimental procedures. We found significant decreases in pain threshold, tolerance, and persistence following the experimental manipulations but found no main effects of rumination or suicide risk. These findings suggest that suicide capability can fluctuate but these changes may occur through a different mechanism and/or differ between individuals at varying levels of suicide risk.

[Pain perception and nonsuicidal self-injurious behavior]

This review focuses on studies of pain threshold and tolerance in individuals with nonsuicidal self-injurious (NSSI) behavior. The data on methods of pain sensitivity studies are presented, with issues in animal modeling of NSSI discussed separately. The results of neuroimaging studies on pain sensitivity in individuals with NSSI are described, along with contribution of genetic factors, psychological variables, and disturbances in opioid and hypothalamic-pituitary-adrenal systems. A critical methodological analysis of the studies on pain sensitivity in individuals with NSSI was performed.

Examining Relationships between Gender, Opioid Dependence, and Distress Tolerance among Patients in Substance Use Disorder Treatment

Background: Opioid abuse/dependence is associated with multiple negative outcomes relative to other forms of substance abuse/dependence, including relapse. Research identifying modifiable characteristics associated with opioid dependence and associated negative outcomes may inform the development of targeted interventions for this high-risk population. One factor warranting investigation is low distress tolerance (DT). Purpose/Objectives: In a sample of patients in substance use disorder (SUD) treatment, the present study examined DT levels among patients with current opioid dependence versus no history of opioid dependence, as well as the moderating role of gender. We predicted that patients with opioid dependence would exhibit lower DT than those without a history of opioid dependence, and that women with opioid dependence would exhibit lower levels of DT than men with opioid dependence. Methods: A sample of 203 patients in residential SUD treatment were administered a series of diagnostic interviews and a behavioral measure of DT. Results: DT did not differ significantly as a function of opioid dependence. However, there was a significant opioid dependence by gender interaction, such that men with current opioid dependence exhibited significantly lower levels of DT than women with opioid dependence and men without a history of opioid dependence. Conclusions/Importance: Findings highlight a modifiable characteristic associated with opioid dependence among men that may be targeted in interventions.

The effect of rumination on recall of emotional words: comparison of dysphoric individuals with and without a history of nonsuicidal self-injury

Prior research and theory has suggested that rumination plays a role in nonsuicidal self-injury (NSSI), and rumination increases recall of negative autobiographical information in dysphoric individuals. Across two studies, we investigated whether rumination (versus distraction) differentially influences the recall of emotional words among dysphoric persons with and without a history of NSSI. Participants encoded unpleasant, neutral, and pleasant words and then were randomly assigned to either focus on the meaning and consequences of their emotions (i.e. rumination) or unrelated thoughts (i.e. distraction) before they were asked to recall encoded words. Across the two studies, we did not find a significant effect of rumination on memory for emotional words among dysphoric people with (Studies 1 and 2) or without a history of NSSI (Study 1). We did find that people were more likely to remember neutral words as opposed to unpleasant or pleasant words across studies, regardless of rumination condition. Together, results from these two well-powered studies provide fairly compelling evidence that rumination after encoding has little to no effect on recall for emotional words in people elevated on symptoms of depression or with NSSI history. These findings can be used to refine theories of rumination and NSSI.

A lab-based study exploring the associations among nonsuicidal self-injury, pain, and emotion among university students

Nonsuicidal self-injury (NSSI; e.g., self-cutting without lethal intent) is a widespread mental health concern among emerging adults in university. Although accumulating evidence suggests that NSSI is primarily an emotion coping behaviour, little is known about variability in emotional response to pain among individuals who self-injure. Recent theory on NSSI suggests that individuals who engage in NSSI to self-punish may experience additional affective gains in response to pain compared to individuals without self-punishment motivations for NSSI and individuals who do not self-injure. To test this hypothesis, 82 undergraduate students (Mage = 21.52 years) were recruited from a mid-sized university, and reported on their emotions three times: at baseline, following a stress-induction task, and after a cold-pressor task. Although all participants showed decreased negative emotions (e.g., hostility, fear) and increased serenity following cold pain, students who engaged in NSSI specifically to self-punish also showed decreased guilt and sadness. The present findings demonstrate that pain may serve to regulate different emotions for students who self-injure depending on their motivations for engaging in NSSI. Additionally, findings suggest that prevention and intervention efforts aimed at reducing the need to self-punish may help to reduce some of the emotionally reinforcing properties of NSSI.

What activities might facilitate personal recovery for adults who continue to self-harm? A meta-synthesis employing the connectedness/hope and optimism/identity/meaning/empowerment framework

Self-harm is an international concern. While treatment in health care focusses on methods to reduce the act, there is less exploration in how to assist adults who are unable to minimize their self-harm. In order to aid these people, in the present systematic review, we employed a qualitative meta-synthesis to explore the lived experience of what activities might facilitate personal recovery for adults who continue to self-harm. Findings were interpreted by drawing on the CHIME framework; a taxonomy of personal recovery comprising of connectedness, hope and optimism, identity, meaning and purpose, and empowerment. The located activities in the review converged on different support groups, and although face-to-face groups were discovered, the majority highlighted the benefits of Internet forums where mutuality and reciprocity were key to promoting personal recovery. Adults desired time to share accounts of themselves, to develop connection and identity. Furthermore, hope was established by group members accepting that self-harm has a role, while congregating with others who did not judge the act. Helping relationships also promoted hope by having a balance between goals and protection against disappointment. The nature of writing online seemingly had cathartic properties fostering meaning, alongside empowerment being facilitated by adults controlling the narrative of their self-harm. It is hoped that these insights might guide self-harm research to develop beyond the confines of minimizing self-injury in health care.

The role of emotional clarity and distress tolerance in deliberate self-harm in a sample of trauma-exposed inpatient adolescents at risk for suicide

OBJECTIVE

The purpose of this study was to examine distress tolerance as a moderator of the relationship between emotional clarity and deliberate self-harm (DSH) in a diverse sample of trauma-exposed adolescents in acute psychiatric care at high risk of suicidal behavior. It was hypothesized that distress tolerance would emerge as a significant moderator, such that the association between emotional clarity and DSH would be significant among youth with high, but not low, distress tolerance.

METHOD

Participants (N=50; 52.0% female; M=15.1years, SD=0.51; 44% White) completed measures of emotion dysregulation, DSH, history of suicide attempts, as well as a behavioral measure of distress tolerance.

RESULTS

Controlling for history of suicide attempts, results revealed a significant interaction between distress tolerance and emotional clarity in relation to DSH. Specifically, emotional clarity difficulties were related to DSH at high, but not low, levels of distress tolerance.

CONCLUSIONS

Findings suggest that DSH among trauma-exposed youth with high rates of past suicide attempts is most likely when low emotion clarity is coupled with a high tolerance for emotional distress. Given that DSH significantly increases risk for suicide among youth with psychiatric needs, assessment of emotional clarity and distress tolerance deficits is apt to be warranted to facilitate identification of these youth for targeted intervention.

Predicting Nonsuicidal Self-Injury in Borderline Personality Disorder Using Ecological Momentary Assessment

Borderline personality disorder (BPD) is a highly comorbid disorder, and these comorbidities increase the impairment associated with BPD. For example, depression, which occurs in the majority of individuals with BPD, increases the likelihood of an individual with BPD to engage in nonsuicidal self-injury (NSSI). Little research, however, has investigated potential mechanisms of NSSI engagement in this population. The current study aimed to fill this gap by examining momentary experiences, levels of distress tolerance, and NSSI among 51 individuals meeting current diagnostic criteria for BPD and a comorbid depressive disorder. Using data from an ecological momentary assessment across 7 days, it was found that daily urges to hurt oneself and impulsive urges, but not daily negative affect or aggressive urges, predicted NSSI occurrence. Furthermore, low levels of distress tolerance was a stronger predictor of NSSI behavior than daily experiences. These findings have important implications with regard to state versus trait dispositions in NSSI engagement among those with BPD and depression.

Anxiety sensitivity mediates gender differences in post-concussive symptoms in a clinical sample

Traumatic brain injury (TBI) is both prevalent and potentially disabling. Extant literature has demonstrated women to report greater post-concussive symptoms (PCS) compared to men, highlighting the necessity of investigations into malleable, gender-linked risk factors for PCS that hold promise for reducing this gender disparity. Anxiety Sensitivity (AS) and Distress Tolerance (DT) are gender-linked risk factors that may be related to PCS. Despite a breadth of research supporting elevated AS and reduced DT in women, no study to date has investigated whether AS and DT mediate gender differences in PCS. The current sample was composed of 59 participants selected from a larger study based on their report of a past TBI. Findings indicated that AS, but not DT, significantly mediated gender differences in PCS. The present results suggest that AS is a cognitive risk factor that can partially account for the gender disparity in the expression of PCS. AS may influence an individual's interpretation of PCS as dangerous, thereby amplifying the perception of PCS severity. This suggests that efforts to reduce the burden of TBI may benefit from targeting AS in prevention and treatment paradigms, especially among women.

Non-suicidal self-injury and frequency of suicide attempts: The role of pain persistence

BACKGROUND

Non-suicidal self-injury (NSSI) and suicidal behavior exhibit a robust association with one another. Research on the contexts within which this relationship is stronger or weaker, however, is limited. The interpersonal theory of suicidal behavior (ITS) posits that NSSI influences suicidal behavior through a habituation to physical pain and, as such, pain tolerance has been theorized to play an important role. We tested whether pain persistence, the difference between pain threshold and pain tolerance, would moderate the relationship between frequency of NSSI and suicidal behavior in both an undergraduate and community sample.

METHOD

Study 1 assessed healthy undergraduates, whereas Study 2 was comprised of community members recruited largely based upon a history of suicidal behavior. Across both samples, participants completed self-report measures of NSSI and a structured interview on suicidal behavior. In both studies, pain was measured using a pressure algometer and, in Study 2, persistence was also assessed using the Enhanced Distress Tolerance Test (DTT-E).

RESULTS

Consistent with the notion that suicidal behavior requires persistence amidst pain and distress, results indicated that the willingness to remain engaged with pain and distress may significantly influence the degree to which NSSI is related to suicidal behavior.

LIMITATIONS

Both studies were limited by a cross-sectional design, which precluded assessments of causality and directionally of effects.

CONCLUSIONS

These results call attention to the potential importance of persistence through pain and/or distress in the association between NSSI and suicidal behavior.

Pain and self-harm: A systematic review

BACKGROUND

A growing body of research has explored altered physical pain threshold and tolerance in non-suicidal self-injury (NSSI) and suicidal self-harm. The evidence, however, is inconsistent such that the nature of the relationship is unclear, and whether or not this effect is also present in suicidal self-harm is equivocal.

METHODS

A keyword search of three major psychological and medical databases (PsycINFO, Medline and Web of Knowledge) was conducted, yielding 1873 records. Following duplicate removal and screening, 25 articles were quality assessed, and included in the final systematic review.

RESULTS

There is strong evidence for increased pain tolerance in NSSI, and some evidence for this in suicidal individuals, but notably, there were no prospective studies. The review found a lack of substantive focus on psychological correlates of altered pain tolerance in this population. Several candidate explanatory mechanisms were proposed within the reviewed studies.

LIMITATIONS

The current review was a narrative systematic review; methods used to assess pain were considered too heterogeneous to conduct a meta-analysis.

CONCLUSIONS

The evidence suggests that there is elevated pain tolerance among those who engage in NSSI. Future prospective research should determine if altered pain tolerance is a cause or a consequence of the behaviour. The identification of psychological correlates of increased pain tolerance is a neglected area of research. It could provide opportunities for treatment/intervention development, if mediating or moderating pathways can be identified. Too few studies have directly investigated candidate explanatory mechanisms to draw definitive conclusions.

A meta-analysis on pain sensitivity in self-injury

Individuals engaging in self-injurious behavior (SIB) frequently report absence of pain during acts of SIB. While altered pain sensitivity is discussed as a risk factor for the engagement in SIB, results have been mixed with considerable variance across reported effect sizes, in particular with respect to the effect of co-morbid psychopathology. The present meta-analysis aimed to summarize the current evidence on pain sensitivity in individuals engaging in SIB and to identify covariates of altered pain processing. Three databases were searched without restrictions. Additionally a hand search was performed and reference lists of included studies were checked for potential studies eligible for inclusion. Thirty-two studies were identified after screening 720 abstracts by two independent reviewers. Studies were included if they reported (i) an empirical investigation, in (ii) humans, including a sample of individuals engaging in (iii) SIB and a group of (iv) healthy controls, (v) receiving painful stimulation. Random-effects meta-analysis was performed on three pain-related outcomes (pain threshold, pain tolerance, pain intensity) and several population- and study-level covariates (i.e. age, sex, clinical etiology) were subjected to meta-regression. Meta-analysis revealed significant main effects associated with medium to large effect sizes for all included outcomes. Individuals engaging in SIB show greater pain threshold and tolerance and report less pain intensity compared to healthy controls. Clinical etiology and age are significant covariates of pain sensitivity in individuals engaging in SIB, such that pain threshold is further increased in borderline personality disorder compared to non-suicidal self-injury. Mechanisms underlying altered pain sensitivity are discussed.

Non-suicidal self-injury and life stress: A systematic meta-analysis and theoretical elaboration

Recent years have seen a considerable growth of interest in the study of life stress and non-suicidal self-injury (NSSI). The current article presents a systematic review of the empirical literature on this association. In addition to providing a comprehensive meta-analysis, the current article includes a qualitative review of the findings for which there were too few cases (i.e., <3) for reliable approximations of effect sizes. Across the studies included in the meta-analysis, a significant but modest relation between life stress and NSSI was found (pooled OR=1.81 [95% CI=1.49-2.21]). After an adjustment was made for publication bias, the estimated effect size was smaller but still significant (pooled OR=1.33 [95% CI=1.08-1.63]). This relation was moderated by sample type, NSSI measure type, and length of period covered by the NSSI measure. The empirical literature is characterized by several methodological limitations, particularly the frequent use of cross-sectional analyses involving temporal overlap between assessments of life stress and NSSI, leaving unclear the precise nature of the relation between these two phenomena (e.g., whether life stress may be a cause, concomitant, or consequence of NSSI). Theoretically informed research utilizing multi-wave designs, assessing life stress and NSSI over relatively brief intervals, and featuring interview-based assessments of these constructs holds promise for advancing our understanding of their relation. The current review concludes with a theoretical elaboration of the association between NSSI and life stress, with the aim of providing a conceptual framework to guide future study in this area.

Self-harm in nurses: prevalence and correlates

AIMS

The aim of this study was to examine the weighed prevalence of self-harm and its correlates among Hong Kong nurses.

BACKGROUND

Recent epidemiological data suggest that the weighted prevalence of past-year suicidality among Hong Kong nurses was found to be 14·9%. Deliberate self-harm was a significant correlate of suicidality. Nonetheless, there are few population-based studies exploring the prevalence of self-harm and its correlates among medical occupational groups in Asia.

DESIGN

The study uses a cross-sectional survey design.

METHOD

Data were collected in Hong Kong over a four-week period from October-November 2013. Statistical methods, including binary and multivariate logistic regression models, were used to examine the weighted prevalence of self-harm and its associated factors in nurses.

RESULTS

A total of 850 nurses participated in the study. Seventy-nine participants (9·3%) reported self-harm in the past year. Nurses aged between 25-44 were at especially high risk of self-harm. Female nurses reported self-harm more than male nurses. The most common forms of self-harm were self-cutting, striking oneself and poisoning oneself. Clinical experience, chronic illness, relationship crises with family members, a family history of self-harm, smoking, symptoms of stress and psychiatric disorder were significantly associated with nurses' self-harm. The positive correlation between psychiatric disorder and self-harm was confirmed.

CONCLUSIONS

There is a need for a raft of self-harm prevention strategies, including a continuous monitoring system in the healthcare setting detecting and managing the risks of self-harm in nurses as part of the ordinary provision for their well-being.

Diagnosis and Characterization of DSM-5 Nonsuicidal Self-Injury Disorder Using the Clinician-Administered Nonsuicidal Self-Injury Disorder Index

Despite the inclusion of nonsuicidal self-injury disorder (NSSID) in the DSM-5, research on NSSID is limited and no studies have examined the full set of DSM-5 NSSID diagnostic criteria. Thus, this study examined the reliability and validity of a new structured diagnostic interview for NSSID (the Clinician-Administered NSSI Disorder Index; CANDI) and provides information on the clinical characteristics and features of DSM-5 NSSID. Data on the interrater reliability, internal consistency, and construct validity of the CANDI and associated characteristics of NSSID were collected in a community sample of young adults (N = 107) with recent recurrent NSSI (≥10 lifetime episodes of NSSI, at least one episode in the past year). Participants completed self-report measures of NSSI characteristics, psychopathology, and emotion dysregulation, as well as diagnostic interviews of borderline personality disorder (BPD) and lifetime mood, anxiety, and substance use disorders. The CANDI demonstrated good interrater reliability and adequate internal consistency. Thirty-seven percent of participants met criteria for NSSID. NSSID was associated with greater clinical and diagnostic severity, including greater NSSI versatility, greater emotion dysregulation and psychopathology, and higher rates of BPD, bipolar disorder, posttraumatic stress disorder, social anxiety disorder, and alcohol dependence. Findings provide support for the reliability, validity, and feasibility of the CANDI.

Development and Validation of a Brief Version of the Difficulties in Emotion Regulation Scale: The DERS-16

The Difficulties in Emotion Regulation Scale (DERS) is a widely-used, theoretically-driven, and psychometrically-sound self-report measure of emotion regulation difficulties. However, at 36-items, the DERS may be challenging to administer in some situations or settings (e.g., in the course of patient care or large-scale epidemiological studies). Consequently, there is a need a briefer version of the DERS. The goal of the present studies was to develop and evaluate a 16-item version of the DERS - the DERS-16. The reliability and validity of the DERS-16 were examined in a clinical sample (N = 96) and two large community samples (Ns = 102 and 482). The validity of the DERS-16 was evaluated comparing the relative strength of the association of the two versions of the DERS with measures of emotion regulation and related constructs, psychopathology, and clinically-relevant behaviors theorized to stem from emotion regulation deficits. Results demonstrate that the DERS-16 has retained excellent internal consistency, good test-retest reliability, and good convergent and discriminant validity. Further, the DERS-16 showed minimal differences in its convergent and discriminant validity with relevant measures when compared to the original DERS. In conclusion, the DERS-16 offers a valid and brief method for the assessment of overall emotion regulation difficulties.

The underlying role of posttraumatic stress disorder symptoms in the association between intimate partner violence and deliberate self-harm among African American women

African American women are at heightened risk for intimate partner violence (IPV) and its negative consequences, including health-compromising behaviors. Deliberate self-harm (DSH) is one clinically-relevant behavior that has been understudied among African American women generally and those with exposure to IPV in particular. To date, no studies have examined factors that may account for the relationship between IPV and DSH. Therefore, the goal of the present study was to examine the intercorrelations among IPV (physical, psychological, and sexual), PTSD, and DSH history and versatility, and the potentially mediating role of PTSD symptoms in the IPV-DSH relation. Participants were 197 African American community women currently experiencing IPV. Sixty participants (31%) reported a history of DSH. Among participants who reported DSH, there was an average endorsement of 2.3 unique forms of deliberate self-harm (i.e., DSH versatility). Significant positive associations were detected among physical IPV severity, psychological IPV severity, PTSD symptom severity, and DSH history and versatility. PTSD symptom severity mediated the relationships between physical and psychological IPV severity and DSH history and versatility. Results highlight the relevance of PTSD symptoms to DSH and suggest that treatments targeting PTSD symptoms may be useful in reducing DSH among IPV-exposed African American women.

Patterns of non-suicidal self-injurious behaviours among college students in India

BACKGROUND

Non-suicidal self-injurious behaviour (NSSI) is a growing concern among youth and rarely reaches the attention of mental health and medical services.

AIMS

The study explored the occurrence, methods, characteristics and reported reasons for NSSI among a sample of college students in India.

METHODS

A total of 470 participants from undergraduate and postgraduate colleges completed the Functional Assessment of Self Mutilation (FASM) questionnaire.

RESULTS

Results indicated that 31.2% of the participants reported NSSI in the past year, with the mean age of onset being 15.9 years. Moderate/severe forms of NSSI were reported by 19.8% of the sample. The most common method was self-hitting (15.2%) followed by cutting or carving skin (13.2%). A majority of self-injurers endorsed multiple methods of NSSI, and there were no significant gender differences in NSSI rates. The NSSI was performed both to regulate internal emotional states (automatic reinforcement) and to influence others in the environment (social reinforcement).The most commonly endorsed reasons for NSSI were 'to feel relaxed' and 'to get control of the situation', while the least frequently endorsed reasons were 'to make others angry' and 'to avoid college, work, or other activities'.

CONCLUSION

The findings underscore the need to increase the awareness and understanding of NSSIs and to plan targeted interventions among college youth.

Investigating the role of self-disgust in nonsuicidal self-injury

Self-directed disgust, a component of self-criticism, may present an important, yet unexplored emotion in the context of nonsuicidal self-injury (NSSI). The aim of this study was to examine the role of self-disgust in NSSI, specifically as a potential mediator in the relations between depression and NSSI as well as sexual abuse and NSSI, and to also better understand characteristics that might differentiate recent and past self-injurers. A total of 549 college students completed measures assessing NSSI, self-disgust, depression, anxiety sensitivity, and physical and sexual abuse. Results indicated self-disgust fully mediated the relation between depressive symptoms and NSSI status and partially mediated the relation between sexual abuse and NSSI status. Additionally, compared to past self-injurers (4.6%; n = 25), recent self-injurers (6.4%; n = 35) endorsed significantly higher self-disgust and depressive symptoms. Self-disgust may be an important component in NSSI and should be addressed in treatment.

Emotional non-acceptance links early life stress and blunted cortisol reactivity to social threat

Early life stress (ELS) has been recently associated with blunted cortisol reactivity and emotion dysregulation, but no study until now examined whether these characteristics are related. The main goal of this study was to examine the potential mediator role of emotion dysregulation in the relation between ELS and cortisol reactivity to social threat. Only women who were free of psychiatric and endocrine disorders, had regular menstrual cycle and did not use oral contraceptives were selected for this study (N=62). After filling in ELS and multidimensional emotion dysregulation measures, participants underwent the Trier Social Stress Test during which cortisol and autonomic responses were assessed. Most participants (85.5%) reported one or more major stressful events (i.e., physical abuse, sexual abuse, major parental conflicts, death of a family or close friend, severe illness) experienced before age 17. ELS was negatively associated with cortisol reactivity and positively associated with skin conductance level (SCL) reactivity, but it did not influence heart rate and respiratory sinus arrhythmia. In addition, ELS was positively related to emotional non-acceptance (i.e., a tendency to develop secondary emotional responses to one's negative emotions), and the latter was negatively related to cortisol responses and positively related to SCL responses. Bootstrapping analyses indicated that emotional non-acceptance was a significant mediator in the relationships between ELS and both cortisol and SCL responses. Emotional non-acceptance is thus one of the psychological mechanisms underlying blunted cortisol and increased sympathetic reactivity in young healthy volunteers with a history of ELS.

Self-injurious behaviors in posttraumatic stress disorder: an examination of potential moderators

BACKGROUND

Despite increasing evidence for a relation between posttraumatic stress disorder (PTSD) and self-injurious behaviors (SIB), limited research has examined the factors that may moderate the associations between PTSD and both nonsuicidal SIB (deliberate self-harm; DSH) and suicidal SIB (suicide attempts). Nonetheless, research suggests that characteristics of the traumatic event, co-occurring borderline personality disorder (BPD), and emotion dysregulation may influence the relations between PTSD and SIB.

METHODS

Thus, the aim of this study was to examine the moderating role of these factors in the association between PTSD and SIB (including history and frequency of DSH and suicide attempts, and DSH versatility) among a sample of substance use disorder inpatients with (n=116) and without (n=130) a history of PTSD.

RESULTS

Results from stepwise regression analyses indicate that sexual assault-related PTSD predicted suicide attempt frequency and DSH versatility among those with PTSD. Furthermore, results from hierarchical linear and logistic regression analyses suggest that co-occurring BPD moderates the relationship between PTSD and both DSH history and versatility and emotion dysregulation moderates the relationship between PTSD and DSH frequency. Specifically, the relations between PTSD and DSH outcomes were stronger among participants with co-occurring BPD and higher levels of emotion dysregulation.

LIMITATIONS

This study is limited by its reliance on cross-sectional, self-report data.

CONCLUSIONS

Despite limitations, findings suggest distinct risk factors for suicide attempts and DSH, and highlight the importance of examining characteristics of the trauma and associated BPD and emotion dysregulation in assessing risk for SIB in PTSD.

The role of executive attention in deliberate self-harm

Although a wealth of literature has examined the role of emotion-related factors in deliberate self-harm (DSH), less is known about neurocognitive factors and DSH. In particular, despite theoretical literature suggesting that deficits in executive attention may contribute to engagement in DSH, studies have not yet examined the functioning of this attentional network among individuals with DSH. The present study sought to address this gap in the literature by examining the functioning of the alerting, orienting, and executive attentional networks among participants with a recent history of DSH (n=15), a past history of DSH (n=18), and no history of DSH (n=21). Controlling for borderline personality pathology and depression symptoms, participants with a recent history of DSH exhibited deficits in executive attention functioning relative to participants without any history of DSH. No differences were found in terms of performance on the alerting or orienting attentional networks. These results provide preliminary support for the association between executive attention deficits and DSH.

Reciprocal effects of parenting and borderline personality disorder symptoms in adolescent girls

Theories of borderline personality disorder (BPD) postulate that high-risk transactions between caregiver and child are important for the development and maintenance of the disorder. Little empirical evidence exists regarding the reciprocal effects of parenting on the development of BPD symptoms in adolescence. The impact of child and caregiver characteristics on this reciprocal relationship is also unknown. Thus, the current study examines bidirectional effects of parenting, specifically harsh punishment practices and caregiver low warmth, and BPD symptoms in girls aged 14-17 years based on annual, longitudinal data from the Pittsburgh Girls Study (N = 2,451) in the context of child and caregiver characteristics. We examined these associations through the use of autoregressive latent trajectory models to differentiate time-specific variations in BPD symptoms and parenting from the stable processes that steadily influence repeated measures within an individual. The developmental trajectories of BPD symptoms and parenting were moderately associated, suggesting a reciprocal relationship. There was some support for time-specific elevations in BPD symptoms predicting subsequent increases in harsh punishment and caregiver low warmth. There was little support for increases in harsh punishment and caregiver low warmth predicting subsequent elevations in BPD symptoms. Child impulsivity and negative affectivity, and caregiver psychopathology were related to parenting trajectories, while only child characteristics predicted BPD trajectories. The results highlight the stability of the reciprocal associations between parenting and BPD trajectories in adolescent girls and add to our understanding of the longitudinal course of BPD in youth.

Emotion: empirical contribution. Maternal borderline personality pathology and infant emotion regulation: examining the influence of maternal emotion-related difficulties and infant attachment

Evidence suggests that maternal borderline personality (BP) pathology increases offspring risk. This study examined the relations between maternal BP pathology and related emotional dysfunction (including emotion regulation [ER] difficulties and emotional intensity/reactivity) and infant ER difficulties. Specifically, we examined both self-focused and caregiver-focused ER behaviors and the modulation of emotional expressions (one indicator of ER in young children) in response to fear- and anger-eliciting stimuli among 101 infants (12 to 23 months old) of mothers with and without clinically relevant BP pathology. The authors also examined the moderating role of mother-infant attachment. Findings of a series of multiple regression mediation analyses revealed an indirect effect of maternal BP pathology on infant ER difficulties through maternal emotional dysfunction, with maternal ER difficulties facilitating an indirect effect of maternal BP pathology on expressivity-related indicators of infant ER difficulties and maternal emotional intensity/reactivity linking maternal BP pathology to lower self-focused ER for infants in insecure-resistant attachment relationships.

Five indices of emotion regulation in participants with a history of nonsuicidal self-injury: a daily diary study

Theory has proposed that nonsuicidal self-injury (NSSI) is a response to intense frequent negative affect (NA) that is difficult to control. Therefore, individual differences that are related to emotion dysregulation should be higher in individuals who engage in NSSI compared to healthy controls. Though current research supports this prediction, this research could be strengthened by corroborating evidence from daily diary studies. The current study used a daily diary protocol to thoroughly examine the emotional correlates of NSSI. Individuals with and without a history of NSSI rated their affect daily for 14 days. This information was used to score multiple indices of emotionality (e.g., mean level, within-person variation, reactivity). The results showed that compared to controls, individuals who engaged in NSSI had higher mean levels, within-person variation, and lower emotional differentiation of NA, but groups did not differ on inertia of NA or reactivity of NA. Moreover, individuals with a history of NSSI reported lower levels of positive affect and lower inertia of positive affect. These results are discussed in terms of affect regulation models of NSSI and treatment implications.

The importance of high distress tolerance in the relationship between nonsuicidal self-injury and suicide potential

Research has indicated that nonsuicidal self-injury (NSSI) and suicidal behavior are strongly related to one another, with a sizable portion of individuals with a history of NSSI also reporting a history of nonlethal suicide attempts. Nonetheless, little research has examined possible moderators of this relationship. One potentially important construct is distress tolerance (DT), which has been shown to be negatively associated with NSSI and positively associated with the acquired capability for suicide. In this study, 93 adult inpatients (54.8% male) receiving treatment for substance use disorders completed a structured interview assessing prior suicidal behavior and questionnaires assessing DT, NSSI, and psychopathology. Results indicated that DT moderates the relationship between NSSI frequency (but not number of NSSI methods) and suicide potential (a continuum ranging from no prior suicidal behavior to suicidal behavior with minimal bodily harm to highly lethal suicidal behavior), ΔR(2) = .04; p < .023; f(2) = .06, with this relation increasing in strength at higher levels of DT. These results are consistent with an emerging line of research indicating that high levels of DT facilitate suicidal behavior in at-risk populations and suggest that the capacity to tolerate aversive physiological and affective arousal might be vital to engagement in serious or lethal suicidal behavior.

Low distress tolerance as an indirect risk factor for suicidal behavior: considering the explanatory role of non-suicidal self-injury

Although some theorists conceptualize the relationship between emotion dysregulation and suicidal behavior as direct, recent research suggests that this relationship may be indirect and mediated by repeated experiences with certain behaviors (e.g., non-suicidal self-injury; NSSI) common among individuals with heightened emotion dysregulation. To date, however, this research has been limited in both scope (e.g., examining few components of emotion dysregulation) and generalizability (e.g., over-emphasis on undergraduate samples). This study sought to extend the research in this area by examining the mediating role of NSSI in the association between one relevant aspect of emotion dysregulation (i.e., low distress tolerance [DT]) and suicidal behavior with a clear intent to die among an at-risk sample of substance use disorder (SUD) patients in residential treatment. SUD patients (N=93) completed a structured interview assessing past suicidal behavior and questionnaires assessing DT and NSSI. Consistent with hypotheses, results revealed a significant indirect association between low DT and lifetime suicide attempts through NSSI frequency. These results suggest that exposure to painful and provocative events through experience with NSSI may be one pathway through which certain facets of emotion dysregulation increase the risk for suicidal behaviors (consistent with theories that individuals low in DT may be unable and/or unwilling to engage in suicidal behavior unless they have experienced sufficient levels of painful and/or provocative events capable of changing their relationship with and experience of pain and fear of death).

Body regard as a moderator of the relation between emotion dysregulation and nonsuicidal self-injury

Despite research documenting a strong association between emotion dysregulation and nonsuicidal self-injury (NSSI), the moderators of this association have received little attention. Thus, it remains unclear why some individuals with heightened emotion dysregulation engage in NSSI and others do not. Body regard (i.e., how one perceives, experiences, and cares for the body) may be one such moderator, explaining the risk for NSSI among some individuals with emotion dysregulation. The current study used structural equation modeling within a sample of 398 undergraduates (26% reporting NSSI, mean frequency = 25.16, SD = 40.5) to test the interactive effect of emotion dysregulation and body regard on NSSI frequency when controlling for negative affect and borderline personality disorder symptoms. The interaction model provided a strong fit to the data and showed that emotion regulation was associated with NSSI only when low levels of body regard were present. Results suggest that body regard may be important to understanding who engages in NSSI within the context of emotion dysregulation. Possible mechanisms underlying the interaction between body regard and emotion dysregulation are discussed along with treatment and prevention implications.

Major Depression and Risky Sexual Behavior among Substance Dependent Patients: The Moderating Roles of Distress Tolerance and Gender

The goal of the present study was to examine the main and interactive effects of major depressive disorder (MDD), distress tolerance (DT), and gender on multiple indices of risky sexual behavior (RSB) within a sample of 185 substance dependent patients in residential substance abuse treatment. Participants were interviewed to establish current MDD (as well as other Axis I and II diagnoses) and completed a behavioral measure of DT, the Paced Auditory Serial Addition Task - Computerized Version. Results provided evidence of a MDD × DT interaction for number of different past year commercial and casual sexual partners with which penetrative sex occurred. Post-hoc analyses demonstrated that participants with current MDD and low DT reported the greatest number of commercial and casual sexual partners. Results highlight one psychological vulnerability (DT) that may improve our understanding of the complex relationship between depression and RSB. Treatment implications of findings are discussed.

Examining the interactive effect of posttraumatic stress disorder, distress tolerance, and gender on residential substance use disorder treatment retention

An extensive body of research has demonstrated that patients with a co-occurring posttraumatic stress disorder (PTSD) and substance use disorder (SUD) diagnosis are at high risk for a wide range of negative clinical outcomes, including treatment noncompletion. However, no studies to date have explored the effect of a PTSD-SUD diagnosis on residential SUD treatment completion, as well as potential moderators of this effect. Consequently, the goal of this study was to examine the interactive effect of a PTSD diagnosis, distress tolerance (DT), and gender on residential SUD treatment retention. Participants were 214 substance-dependent patients consecutively admitted to a residential SUD treatment facility. Participants were administered diagnostic interviews, completed a laboratory-based measure of DT, and were followed throughout the course of treatment. Although no significant main effects were found, results did reveal a significant PTSD × gender × DT interaction. Post hoc analyses indicated that, among men, those with a current diagnosis of PTSD and low DT completed a significantly lower proportion of residential SUD treatment compared to all other groups. The implications of the study's findings for identifying ways to improve residential SUD treatment retention among patients with a PTSD-SUD diagnosis are discussed.

Nonsuicidal self-injury and diminished pain perception: the role of emotion dysregulation

Nonsuicidal self-injury (NSSI) is the deliberate destruction of one's own body tissue in the absence of suicidal intent (e.g., cutting or burning the skin). Previous studies have found that people with a history of NSSI display diminished pain perception. However, it remains unclear why this effect occurs. In the present study, we used a sample of participants with (n = 25) and without (n = 47) a history of NSSI to test the hypothesis that emotion dysregulation partially explains why NSSI is associated with diminished pain perception. Pain perception was quantified as pain threshold, pain tolerance, and pain intensity ratings assessed during the cold pressor task. Nonsuicidal self-injury was associated with increased emotion dysregulation and diminished pain perception. Results showed that emotion dysregulation was correlated with diminished pain perception within both groups, demonstrating that this association exists regardless of NSSI history. Results also specified that emotion dysregulation partially accounted for the association between NSSI and pain tolerance but not other pain variables. Overall, results were consistent with the hypothesis that emotion dysregulation may increase NSSI risk in part by increasing the willingness to experience the pain involved in self-injury. Studies are needed to more directly investigate this hypothesis.