Nonsuicidal self-injury and interpersonal violence in U.S. veterans seeking help for posttraumatic stress disorder

Nonsuicidal self-injury characteristics: A mixed methods analysis of differences between veterans and civilians

Nonsuicidal self-injury (NSSI) is a well-established risk factor for suicidal behavior, with certain NSSI characteristics being associated with increased risk. In the United States (U.S.), the veteran suicide rate is elevated, though lifetime prevalence rates of NSSI appear similar between veterans and civilians. There is limited research that directly compares veterans and civilians across multiple NSSI characteristics to examine between-group differences in NSSI behavior and provide important context for the application of NSSI research with the veteran population. This study examined differences between U.S. veterans and civilians with a history of suicidal ideation across several NSSI characteristics, including method, severity, age of onset, shame, distress, and reason for initial NSSI engagement. A sample of 527 veterans and civilians completed measures of direct and indirect NSSI behaviors along with supplemental questions designed to further assess endorsed NSSI behaviors. Additionally, respondents provided written responses to an open-ended question about their reasons for initial engagement in NSSI, which were coded for post-hoc analysis. Chi-square difference tests and t-tests were conducted, revealing significant group differences between veterans and civilians in NSSI method, lifetime versatility, age of onset, age at last occurrence, and reasons for initial engagement. No significant differences were found in NSSI frequency, severity, shame, or distress. These findings provide valuable information on similarities and differences in NSSI behavior characteristics between U.S. veterans and civilians with lifetime suicidal ideation to inform future research and the assessment of NSSI in these populations.

The Prevalence of Nonsuicidal Self-Injury in Military Personnel: A Systematic Review and Meta-Analysis

Military service members and veterans (SMVs) are at risk for self-directed violence, including nonsuicidal self-injury (NSSI). While NSSI is an important construct worthy of independent study, it is understudied among SMVs and, when included in research, typically examined in the context of suicide risk. Consequently, lifetime prevalence rate estimates of NSSI among SMVs vary. This Preferred Reporting Items for Systematic Reviews and Meta-Analyses systematic review and meta-analysis estimated the average lifetime NSSI prevalence among SMVs and explored demographic and methodological factors that may account for observed variability. Based on a search of Ovid MEDLINE, Embase, PsycINFO, and Web of Science, 47 samples from 42 articles across five countries met inclusion criteria. Results revealed an average NSSI lifetime prevalence rate of 15.76% among SMVs. Significantly higher prevalence rates were observed among clinical (28.14%) versus community (11.28%) samples and studies using interviews to assess NSSI (23.56%) versus self-report (13.44%) or chart review (7.84%). Lifetime prevalence increased as publication year increased and decreased as sample size increased. In contrast to prior literature, prevalence rates were comparable between active-duty SMVs, and studies collecting data anonymously versus those that did not. Lifetime prevalence was not moderated by age, gender, race, country, primary research focus, quality of NSSI operationalization, or whether NSSI methods were assessed. Findings suggest NSSI is a pervasive problem among military personnel, particularly within clinical settings, highlighting the need for systematic assessment of this important but understudied clinical phenomenon among SMVs. Further research is necessary to elucidate additional risk factors for NSSI among SMVs, including trauma exposure.

Nonsuicidal self-injury among veterans is associated with psychosocial impairment, suicidal thoughts and behaviors, and underutilization of mental health services

Nonsuicidal self-injury (NSSI) is a robust predictor of suicide attempts. However, understanding of NSSI and associated treatment utilization among Veterans is limited. Although impairment may be assumed, few studies examine the association between NSSI and psychosocial functioning, a core component of the rehabilitation framework of mental health. In a national survey of Veterans, current NSSI (n = 88) was associated with higher rates of suicidal thoughts and behaviors and more severe psychosocial impairment after adjusting for demographics and probable diagnoses of posttraumatic stress disorder, major depressive disorder, and alcohol use disorder, compared to Veterans without NSSI (n = 979). Only half of Veterans with NSSI were engaged with mental health services, with few appointments attended, suggesting that these Veterans are not receiving treatment interventions. Results underscore the adverse outcomes associated with NSSI. Underutilization of mental health services highlights the importance of screening for NSSI among Veterans to improve psychosocial outcomes.

Nonsuicidal self-injury in veterans: Prevalence, clinical characteristics, and gender differences from a national cohort

Nonsuicidal self-injury (NSSI) is a robust predictor of suicidal thoughts and behaviors; however, while there are typically only small differences observed in the prevalence of NSSI between men and women, this condition has been largely overlooked and underestimated among men. Assessing NSSI methods more common in men may address misidentification as well as allow for more precise NSSI prevalence estimates. Survey data from a national sample of Gulf War I-Era veterans (N = 1063) was used to estimate the prevalence of NSSI and compare prevalence of NSSI methods between men and women veterans. Demographic and clinical correlates of NSSI engagement were also examined. The national lifetime prevalence rate of NSSI among Gulf War I-Era veterans was 22.40%, whereas the past year prevalence rate was 8.10%. In both men and women, wall/object punching was the most common NSSI method endorsed across the lifetime. Men had slightly higher overall NSSI prevalence rates compared with women. This study highlights the need to systematically assess NSSI, particularly among veterans, to better identify, and consequently treat, NSSI in men. This is the first available prevalence estimate of NSSI to include the assessment of wall/object punching in a national sample of adult veterans.

Different Ways to Drown Out the Pain: A Meta-Analysis of the Association Between Nonsuicidal Self-Injury and Alcohol Use

OBJECTIVE

There is a significant overlap in the motivations for nonsuicidal self-injury (NSSI) and alcohol use. Moreover, several theories would predict that more frequent alcohol use is likely associated with more NSSI engagement. Still, the size and direction of this association has not been well documented in the literature.

METHOD

To address this gap, the goal of this article was to conduct a meta-analysis of the relation between alcohol use and NSSI.

RESULTS

Across 57 samples and 141,669 participants, we found that there was a significant positive association between NSSI and alcohol use, odds ratio = 1.78, 95% confidence interval [1.53, 2.07], k = 64, m = 52. Moderator analyses found that this effect was stronger for younger samples and samples with more severe alcohol use problems.

CONCLUSIONS

These results help establish a link between NSSI and alcohol use. Implications and future directions for NSSI research and intervention are discussed.HighlightsThere are several reasons to think that NSSI and alcohol use are linked.No reviews or meta-analyses have been conducted.We found a significant and small effect linking greater NSSI with greater alcohol use.

Implicit Associations of Nonsuicidal Self-Injury with Relief in Posttraumatic Stress and Depressive Disorders

OBJECTIVE

Although once considered a defining feature of borderline personality disorder, research has found high rates of NSSI among individuals with other psychiatric disorders, particularly posttraumatic stress disorder (PTSD) and depressive disorders. A recent study from our research team found that lifetime PTSD and depressive disorders were associated with unique self-reported NSSI motives. Given well-established limitations of assessing motives via self-report measures, the present study sought to extend this line of research by using a novel laboratory measure of the implicit NSSI-relief association to examine NSSI emotional relief motives.

METHOD

A subset of participants from our previous study (N = 109) completed diagnostic interviews and the laboratory-based DSH-Relief Implicit Association Test (IAT).

RESULTS

Findings indicated that individuals with lifetime PTSD evidenced stronger NSSI-relief associations than those without PTSD. Further, this main effect was qualified by a PTSD by depressive disorder interaction, such that stronger NSSI-relief associations were found among individuals with lifetime PTSD but no lifetime depressive disorder than among individuals without a history of either PTSD or a depressive disorder.

CONCLUSIONS

Results highlight the importance of investigating NSSI motives associated with different symptom profiles using a multi-method approach.

A Rhesus Monkey Model of Non-suicidal Self-Injury

Non-suicidal self-injury (NSSI) is a type of behavioral pathology seen not only in a variety of clinical conditions but also among non-clinical populations, particularly adolescents and young adults. With the exception of rare genetic conditions that give rise to self-harming behaviors, the etiology of NSSI and the events that trigger specific episodes of this behavior remain poorly understood. This review presents the features of an important, extensively studied animal model of NSSI, namely spontaneously occurring self-injurious behavior (SIB) in rhesus macaque monkeys. We compare and contrast rhesus monkey SIB with NSSI with respect to form, prevalence rates, environmental and biological risk factors, behavioral correlates, proposed functions, and treatment modalities. Many parallels between rhesus monkey SIB and NSSI are demonstrated, which supports the validity of this animal model across several domains. Determining the etiology of spontaneously occurring SIB in monkeys, its underlying biological mechanisms, and which pharmacological agents are most effective for treating the disorder may aid in identifying potential risk factors for the occurrence of NSSI in humans and developing medications for severe cases that are resistant to conventional psychotherapeutic approaches.

Prevalence and risk factors for non-suicidal self-injury among patients with depression or bipolar disorder in China

BACKGROUNDS

Non-suicidal self-injury is a serious health problem among patients with depression or bipolar disorder. However, few studies within the Chinese context have investigated the prevalence of NSSI and its risk factors in above populations. The purpose of this study was to investigate the prevalence of non-suicidal self-injury and its risk factors in patients with depression or bipolar disorder in China.

METHODS

The final sample comprised of 394 inpatients(M_age = 29.71; SD_age = 11.95) with depression or bipolar disorder from two psychiatric hospitals in Beijing, China. A General Demographic Data Form, the Non-suicidal Self-injury Questionnaire(NSSI-Q), Impulsivity Item and the Adverse Childhood Experiences-International Questionnaire(ACE-IQ) were completed by all patients.

RESULTS

Of the 394 patients examined, 245(62.2%) of this sample reported NSSI in past year. Of the 245 patients with NSSI, 135(55.1%) were diagnosed with depression and 110(44.9%) were diagnosed with bipolar disorder. The most common methods of NSSI for female was "pinching"(23.1%) and "scratching"(22.8%), while for male it was "hiting hard objects"(12.7%). By multivariate regression analysis, young age, unemployment, a higher monthly family income, single, impulsivity, long duration of illness and ACEs were risk factors for NSSI in patients with depression and bipolar disorder(P<0.05).

CONCLUSIONS

Our study points to the fact that there was an unfortunate message about the prevalence of NSSI among patients with depression or bipolar disorder in China. It is necessary not only to raise the awareness of NSSI in families and society, but also to formulate targeted assessment and intervention. Moreover, future research should not only focus on individuals being hospitalized, but should be representative of individuals treated at home or in the community because there are no national statistics on NSSI among such patients in China.

Exploring the role of anger in nonsuicidal self-injury in veterans

Up to 14% of veterans engage in nonsuicidal self-injury (NSSI) in their lifetime and this behavior is a relatively strong predictor of suicidal behavior compared to other identified risk factors. Further, NSSI is a clinically relevant behavior in its own right; it is associated with more severe psychopathology as well as bodily harm that sometimes requires medical intervention. Therefore, a better understanding of NSSI may help inform suicide prevention efforts as well as mental healthcare strategies for veterans. Anger may be relevant to understanding NSSI in veterans. Over 60% of veterans report difficulties managing anger and this emotion is strongly associated with engagement in NSSI. However, no research has explored the extent to which anger is present prior to NSSI or whether anger is associated with specific NSSI methods or functions in veterans. The purpose of this study was to explore whether anger was associated with engagement in specific NSSI methods, and whether anger uniquely predicted any functions of NSSI while controlling for the presence of other basic negative emotions (fear and sadness). An existing dataset of 61 veterans who reported engaging in NSSI in the past year was analyzed. Results indicated anger was the most common emotional antecedent to NSSI. Further, anger was associated with several methods of NSSI including burning oneself with a cigarette, carving pictures, designs or other marks into skin, sticking sharp objects into skin, severely scratching oneself, head banging, punching oneself, and punching walls or objects. Finally, when controlling for the presence of other negative emotions, anger was associated with engaging in NSSI to relieve tension, stop feeling numb, communicate with others, feel alive, get help from others, and prove to oneself how bad things are. These results highlight the importance of assessing and treating dysregulated anger in veterans who engage in self-harming behavior.

Cannabinoid use and self-injurious behaviours: A systematic review and meta-analysis

BACKGROUND

The increasing availability of high-potency cannabis-derived compounds and the use of synthetic cannabinoids may be responsible for severe side effects like cognitive impairment, psychosis or self-injurious behaviours (SIB). In particular, SIB like non-suicidal self-injury (NSSI) and deliberate self-harm (DSH) raise growing concern as a possible consequence of cannabis use. However, the research to date has not addressed the relationship between cannabinoid use and SIB systematically.

METHODS

We conducted a systematic review on PubMed up to March 2020, using search terms related to cannabinoids and SIB.

RESULTS

The search yielded a total of 440 abstracts. Of those, 37 studies published between 1995 and 2020 were eligible for inclusion. Cannabinoid use was significantly associated with SIB at the cross-sectional (OR=1.569, 95%CI [1.167-2.108]) and longitudinal (OR=2.569, 95%CI [2.207-3.256]) level. Chronic use, presence of mental disorders, depressive symptoms, emotional dysregulation and impulsive traits might further increase the likelihood of self-harm in cannabis users. Synthetic cannabinoids may trigger highly destructive SIB mainly through the psychotomimetic properties of these compounds.

CONCLUSION

Cannabinoid use was associated with an increased prevalence of self-injury and may act as a causative factor with a duration-dependent manner. Emotional regulation and behavioural impulsivity functions might crucially moderate this association. Future studies should further investigate the mechanisms underlying this association, while exploring potential therapeutic applications of substances modulating the endocannabinoid system.

Suicidal ideation, suicide attempt, and non-suicidal self-injury among female veterans: Prevalence, timing, and onset

BACKGROUND

Suicide rates among female veterans have continued to increase, particularly among those not using Veterans Health Administration (VHA) care. Nonetheless, suicide research has rarely focused on female veterans, particularly non-VHA users. The present study examined the prevalence and onset of suicidal ideation (SI), suicide attempt (SA), and non-suicidal self-injury (NSSI) in relation to military service among female veterans. Additionally, current, past, and never VHA users were compared in regard to SI, SA, and NSSI prevalence.

METHODS

Female veterans (n = 439) participated in a national, cross-sectional survey.

RESULTS

Lifetime prevalence of SI (47.9%), SA (17.7%), and NSSI (13.2%) were high. Participants were more likely to report experiencing SI and SA following separation, compared to preceding (SI, SA) or during (SI only) military service, controlling for time at risk. However, onset was more likely to occur prior to military service, compared to after separation, for SI, SA, and NSSI. In age-adjusted analyses, current and past users of VHA care were more likely to report experiencing lifetime SI, compared to those who never used VHA care. However, when adjusting for service era, past and never VHA users did not significantly differ.

LIMITATIONS

Cross-sectional design, retrospective recall, and convenience sample.

CONCLUSIONS

For female veterans, onset of SI, SA, and NSSI appears to most commonly occur before military service. However, SI and SA prevalence are highest following separation, suggesting a period warranting additional support and intervention. Results underscore the need for continued suicide surveillance, prevention, and intervention efforts for female veterans, especially current VHA users.

Characteristics of nonsuicidal self-injury among veterans

OBJECTIVE

The current study aimed to (a) assess basic nonsuicidal self-injury (NSSI) characteristics using a validated clinical interview among a sample of veterans not recruited for specific diagnostic or environmental criteria and (b) examine the relation between NSSI and medical severity of prior suicide attempts (SAs) among veterans.

DESIGN

We conducted secondary data analyses among a combined sample of veterans (N = 165) from two parent studies conducted at a large VA Medical Center that implemented identical recruitment protocols. No psychiatric criteria were utilized for inclusion or exclusion purposes.

RESULTS

Approximately 16% of participants reported NSSI history and almost 21% reported SA history. NSSI history was associated with probability of prior SA but not the medical severity of prior SA.

CONCLUSIONS

NSSI is a prevalent concern among veterans and is associated with probability of SA. It remains unclear whether prior NSSI is associated with more medically serious SA in this population.

DSM-5 personality domains as correlates of non-suicidal self-injury severity in an Italian sample of adolescent inpatients with self-destructive behaviour

To evaluate the associations between DSM-5 alternative model of personality disorder dysfunctional personality domains and the clinician's ratings of non-suicidal self-injury (NSSI) severity, a sample of consecutively admitted Italian adolescent inpatients (N = 100) were administered the Italian translations of the DSM-5 Clinician Rating Scale-NSSI (CRS-NSSI), the Personality Inventory for DSM-5 (PID-5), the Structured Clinical Interview for DSM-IV Axis II Personality Disorders, Version 2.0 (SCID-II) and the Children's Depression Inventory (CDI). Bivariate association analyses showed that PID-5 negative affectivity scores and CDI total score were significantly associated with CRS-NSSI ratings. PID-5 negative affectivity score proved to be a significant predictor of the CRS-NSSI score even when the effect of the CDI total score was held constant. Our results highlighted that specific risk factors for NSSI severity may be identified even among NSSI adolescents. © 2019 John Wiley & Sons, Ltd.

Non-suicidal self-injury prevalence, course, and association with suicidal thoughts and behaviors in two large, representative samples of US Army soldiers

BACKGROUND

Non-suicidal self-injury (NSSI) prospectively predicts suicidal thoughts and behaviors in civilian populations. Despite high rates of suicide among US military members, little is known about the prevalence and course of NSSI, or how NSSI relates to suicidal thoughts and behaviors, in military personnel.

METHODS

We conducted secondary analyses of two representative surveys of active-duty soldiers (N = 21 449) and newly enlisted soldiers (N = 38 507) from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS).

RESULTS

The lifetime prevalence of NSSI is 6.3% (1.2% 12-month prevalence) in active-duty soldiers and 7.9% (1.3% 12-month prevalence) in new soldiers. Demographic risk factors for lifetime NSSI include female sex, younger age, non-Hispanic white ethnicity, never having married, and lower educational attainment. The association of NSSI with temporally primary internalizing and externalizing disorders varies by service history (new v. active-duty soldiers) and gender (men v. women). In both active-duty and new soldiers, NSSI is associated with increased odds of subsequent onset of suicidal ideation [adjusted odds ratio (OR) = 1.66-1.81] and suicide attempts (adjusted OR = 2.02-2.43), although not with the transition from ideation to attempt (adjusted OR = 0.92-1.36). Soldiers with a history of NSSI are more likely to have made multiple suicide attempts, compared with soldiers without NSSI.

CONCLUSIONS

NSSI is prevalent among US Army soldiers and is associated with significantly increased odds of later suicidal thoughts and behaviors, even after NSSI has resolved. Suicide risk assessments in military populations should screen for history of NSSI.