The environmental, interpersonal, and affective context of nonsuicidal self-injury urges in daily life

A systematic review of interpersonal processes and their measurement within experience sampling studies of self-injurious thoughts and behaviours

Self-injurious thoughts and behaviours (SITBs) are a leading cause of death, and interpersonal processes (IPs) appear to play a role in SITBs. This systematic review synthesises the literature on IPs and SITBs in daily life and addresses four critical questions: (1) Which IPs have been assessed and how, (2) How are differences in IPs between individuals associated with SITBs?, (3) How are differences in IPs within individuals associated with SITBs? and (4) Do IPs relate differently to self-injurious thoughts than behaviours? Our review followed PRISMA guidelines and eligible literature was screened until 25 April 2024. We identified 58 Experience Sampling studies (32.76% daily-diary studies) of which most focused on IPs from major SITBs theories (e.g., thwarted belongingness) but largely used inconsistent operationalizations. Results from 39 studies investigating within-person associations were mixed. Based on 26 studies, whether differences in IPs between individuals relate to SITBs remains unclear. Three studies have investigated whether IPs relate to the transition from thoughts to behaviours, but temporal models are needed to draw firm conclusions. Studies investigating IPs and SITBs in daily life are largely inconclusive. Psychometrically validated measures are warranted, and future daily-life studies would benefit from drawing on ideation-to-action frameworks.

The Short-Term Course of Nonsuicidal Self-Injury Among Individuals Seeking Psychiatric Treatment

Importance

A major portion of adolescents and adults seeking psychiatric treatment report nonsuicidal self-injury (NSSI) within the past month, yet the short-term course of NSSI among these patients remains poorly understood.

Objective

To advance the understanding of the short-term course of NSSI cognitions (ie, thoughts, urges, and self-efficacy to resist self-injury) and behavior.

Design, Setting, and Participants

A cohort study was conducted using an intensive longitudinal design with ecological momentary assessment, including 6 daily surveys and event registrations of self-injury for 28 days. Data were collected from June 2021 to August 2023. Individuals using mental health services in the Flanders region in Belgium reporting past-month NSSI urges and/or behavior at intake were recruited by referral.

Main Outcomes and Measures

Nonsuicidal self-injury thoughts, urges, self-efficacy, and behavior. Sociodemographic and clinical baseline characteristics served as between-person variables. Descriptive and variability statistics and dynamic structural equation modeling were used.

Results

Participants completed a mean (SD) of 121 (34.5) surveys, totaling 15 098 longitudinal assessments (median adherence, 78.6%; IQR, 59.5%-88.7%). Among 125 patients (87.2% female; median age, 22.0 [range, 15-39] years; 52.8% heterosexual), NSSI thoughts and urges were present during most assessments but were low in intensity (individual means [SD] on a 0- to 6-point scale, 1.52 [1.13] for urges; 1.57 [1.18] for thoughts). The prevalence of NSSI behavior was 84.0% monthly, 49.90% weekly, and 18.19% daily. Between-patient variability was substantial (intraclass correlation coefficient, 0.43-0.47; range of individual means for cognitions, 0-6; individual frequency behavior, 0-103), with recency and frequency of NSSI thoughts and behavior at intake consistently associated with individual differences in the course of NSSI. The greatest variability was observed within patients (root mean square of successive differences from 1.31 for self-efficacy to 1.40 for instability of thoughts), characterized by changes in the intensity of cognitions by more than 1 within-person SD between assessments less than 2 hours apart in 1 of 5 instances. Nonsuicidal self-injury behavior is rare in the morning, increased in the afternoon, and most frequent in the evening. Nonsuicidal self-injury cognitions were contemporaneous and temporally associated with each other's course, with higher-than-usual thoughts and lower self-efficacy uniquely signaling heightened risk for NSSI behavior in the next 2 hours.

Conclusions and Relevance

In this cohort study of treatment-seeking individuals, NSSI cognitions and behavior appeared to be dynamic over the short term. These findings suggest the potential utility of self-monitoring outside the therapy setting and the need to focus assessment and interventions on the evening hours.

A Daily Diary Study of the Relation between Stress and Nonsuicidal Self-Injury and the Moderating Role of Emotion Dysregulation in Emerging Adulthood

Research on exposure to stressors and nonsuicidal self-injury (NSSI) in daily life has been lacking, particularly among emerging adults (aged 18-25 years). The aim of this study was to determine whether daily stressors predicted same-day and next-day NSSI thoughts and engagement, and whether emotion dysregulation moderated this relation. Participants included 160 emerging adults (83% female, Mage = 19.75, SD = 1.8, 44% White, 22% East Asian, 11% South Asian, and 23% other) who completed a baseline assessment and 14 days of daily diary entries which resulted in 1982 daily assessments (median compliance = 86%; IQR = 12-14). It was found that daily stressors significantly predicted same-day, but not next-day, NSSI thoughts and engagement and this relation was more pronounced for individuals with greater emotion dysregulation. The present study provides new insight into when individuals may be most at risk for NSSI, as well as which individuals may be most vulnerable.

A comparison of retrospectively reported and ecological momentary assessment-reported perceived social support in predicting ecological momentary assessment-reported non-suicidal self-injury

INTRODUCTION

Non-suicidal self-injury (NSSI) urges and behaviors are associated with lower perceived social support and related constructs (e.g., perceived rejection). However, no studies have examined the concordance of retrospective (baseline) and ecological momentary assessment (EMA) perceived social support assessments. Retrospective and EMA reports are often only weakly to moderately correlated; measurement approaches may, therefore, impact observed associations between variables. We tested whether average EMA-reported perceived emotional social support uniquely predicts EMA-reported NSSI urges and behaviors above baseline-reported retrospective self-report of perceived emotional social support alone.

METHODS

93 young adults (ages 18-34) with past-month NSSI urges or behaviors and lifetime NSSI behaviors completed a semi-structured interview, self-report surveys, and a 2-week EMA protocol.

RESULTS

Baseline- and EMA-reported perceived emotional social support were positively correlated (Kendall's tau-b = 0.51). Average EMA-reported social support was uniquely associated with EMA-reported NSSI urges but not NSSI behaviors.

CONCLUSIONS

EMA-reported perceived emotional social support captured information not represented by baseline reports alone, but improvement in model fit was modest. EMA-reported social support may further improve the estimation of EMA-reported NSSI urges if modeled as a proximal predictor of NSSI. Further work is needed to clarify temporal directions between social support and NSSI urges. Limitations are discussed.

How does emotional abuse affect adolescents' non-suicidal self-injury urges? A moderated chain mediation model

BACKGROUND

Studying non-suicidal self-injury (NSSI) among adolescents has high clinical significance. Its urges have been identified as a potential predictor of NSSI behavior and may serve as a crucial intervention target.

OBJECTIVE

This study uses a moderated chain mediation model to explore the relationship between emotional abuse and adolescent NSSI urges. Additionally, we examine the mediating roles of ego depletion and self-esteem and the moderating effect of resilience.

PARTICIPANTS AND SETTING

We recruited 1129 Chinese adolescents (age M = 16.68; SD = 0.78; 49.4 % men) from secondary vocational schools in China.

METHODS

We assessed emotional abuse, ego depletion, self-esteem, and NSSI urges in a longitudinal investigation across two time points (T1: March 2023, T2: June 2023).

RESULTS

After controlling for age, sex, NSSI urges and self-esteem at T1, our study validates a moderated chain mediation model and finds that the mediating effect via self-esteem is 0.026 (95%CI = [0.011,0.046]), and the chain mediating effect via ego depletion and self-esteem is 0.031 (95%CI = [0.022,0.045]), whereas the direct effect of emotional abuse T1 on NSSI urges T2 is not significant (DE = 0.082, 95%CI = [-0.002, 0.167]) and the mediating effect via ego depletion is also not significant (IE = -0.003, 95%CI = [-0.022, 0.015]). Resilience moderates the impact of emotional abuse on ego depletion (β = 0.09, p < 0.01).

CONCLUSIONS

These findings suggest that ego depletion and self-esteem are potential mechanisms related to emotional abuse and adolescents' NSSI urges, whereas resilience can play a moderating role in reducing ego depletion.

Examining the dynamic relationship between nonsuicidal self-injury and alcohol use experiences

INTRODUCTION

Nonsuicidal self-injury (NSSI) is a prevalent and concerning behavior and its risk pathways require a greater understanding, particularly in predicting short-term risk. Although the literature has supported a between-person link among NSSI and alcohol use, limited research has directly examined the nuances of this relationship at the within-person level using intensive longitudinal data.

METHOD

Utilizing two independent samples (total n = 85), the current study examined bidirectional, concurrent and prospective risk relationships between NSSI and alcohol, considering both urges and behavior engagement, via ecological momentary assessment.

RESULTS

Findings demonstrate concurrent, within-person relationships between NSSI urges and alcohol urges, as well as alcohol use. Alternatively, prospective between-person findings demonstrated negative relationships between NSSI urges and alcohol use, as well as alcohol urges and NSSI acts; however, this may represent suppression effects as associations were positive with the removal of autoregressive effects.

CONCLUSIONS

Together, findings support proximal risk relationships between NSSI and alcohol experiences that, for urges in particular, is bidirectional.

Neural Reactivity to Social Punishment Predicts Future Engagement in Nonsuicidal Self-injury Among Peer-Rejected Adolescents

BACKGROUND

Rates of nonsuicidal self-injury (NSSI) increase dramatically in adolescence. Affective reactivity and adverse social experiences have been linked to NSSI, but less is known about whether these factors may separately or interactively predict NSSI, especially longitudinally. This study combined functional magnetic resonance imaging and a sociometric measure to test whether a combination of neural (e.g., amygdala) reactivity to social punishment and peer-nominated peer acceptance/rejection predicts NSSI longitudinally in adolescence. Amygdala reactivity was examined as a potential neural marker of affective reactivity to social punishment, which may heighten NSSI risk in contexts of social adversity.

METHODS

One hundred twenty-five adolescents (63 female) completed a social incentive delay task during neuroimaging and school-based peer nominations to measure peer acceptance/rejection. NSSI engagement was assessed at baseline and 1-year follow-up.

RESULTS

Greater amygdala reactivity to social punishment predicted greater NSSI engagement 1 year later among adolescents with high peer rejection. This effect for the amygdala was specific to social punishment (vs. reward) and held when controlling for biological sex and pubertal development. Exploratory analyses found that ventral striatum reactivity to social reward and punishment similarly interacted with peer rejection to predict NSSI but that amygdala connectivity with salience network regions did not.

CONCLUSIONS

Amygdala reactivity to social punishment, in combination with high peer rejection, may increase NSSI risk in adolescence, possibly via heightened affective reactivity to adverse social experiences. Objective measures of neurobiological and social risk factors may improve prediction of NSSI, while therapeutic approaches that target affective reactivity and increase prosocial skills may protect against NSSI in adolescence.

Measuring affect in daily life: A multilevel psychometric evaluation of the PANAS-X across four ecological momentary assessment samples

While there is strong evidence for the psychometric reliability of the Positive and Negative Affect Schedule-Expanded Form (PANAS-X) in cross-sectional studies, the between- and within-person psychometric performance of the PANAS-X in an intensive longitudinal framework is less understood. As affect is thought to be dynamic and responsive to context, this study investigated the multilevel reliability of PANAS-X Positive Affect, Negative Affect, Fear, Sadness, and Hostility scales. Generalizability theory and structural equation modeling techniques (coefficient ω) were employed in four ecological momentary assessment samples (N = 309; 41,261 reports). Results demonstrate that the PANAS-X scales, including short versions of the Positive and Negative Affect scales, can reliably detect between-person differences. PANAS-X scales also were able to reliably measure within-person change, though these estimates may be impacted by scale content and study design. These results support the use of the PANAS-X in daily life research to intensively measure affect in the natural environment. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Does self-harm have the desired effect? Comparing non-suicidal self-injury to high-urge moments in an ambulatory assessment design

All theoretical models of non-suicidal self-injury (NSSI) posit that regulation of negative affect (NA) is a central motive for NSSI, and cross-sectional work supports this. However, previous ambulatory assessment (AA) studies that examined NSSI found mixed results. We investigated the affect regulation function of NSSI in 51 women with DSM-5 NSSI disorder in a 15-day AA study with five random daily prompts and self-initiated NSSI prompts. We extend previous work by i) comparing NSSI moments to moments of a high-urge for NSSI, ii) adding high-frequency sampling following NSSI and high-urge moments, and iii) including tension as a dependent variable. We hypothesized that NA and tension would show a steeper decrease following NSSI than following high-urge moments, if NSSI was effective in reducing NA and tension. Results showed that the significant linear NA decline following NSSI was not steeper than that following high-urge moments. For aversive tension, we found that NSSI was associated with a significant linear decrease in tension, whereas resisting an urge was not. High-urge moments were better described by an inverted U-shaped pattern, likewise leading to decreased NA and tension following the reported urge. In exploratory analyses, we provide visualized clustering of the NA and tension trajectories surrounding NSSI using k-means and relate these to participants' self-rated effectiveness of the NSSI events. Findings indicate that resisting an urge may also be effective in managing NA and tension and underline the utility of interventions such as urge-surfing.

The relationship between emptiness and suicide and self-injury urges in borderline personality disorder

INTRODUCTION

Suicide and self-injury (SSI) are pervasive among individuals with borderline personality disorder (BPD), yet little research has examined factors that increase SSI urges among those with BPD. Emptiness is a diagnostic criterion of BPD that is associated with SSI behaviors, but its impact on SSI urges in BPD is poorly understood. This study investigates the association between emptiness and SSI urges at baseline and in response to a stressor (i.e., reactivity) among individuals with BPD.

METHODS

Forty individuals with BPD participated in an experimental procedure where they rated their degree of emptiness and SSI urges at baseline and in response to an interpersonal stressor. Generalized estimating equations tested whether emptiness predicts baseline SSI urges and SSI urge reactivity.

RESULTS

Higher emptiness predicted higher baseline suicide urges (B = 0.006, SE = 0.002, p < 0.001), but not baseline self-injury urges (p = 0.081). Emptiness did not significantly predict suicide urge reactivity (p = 0.731) nor self-injury urge reactivity (p = 0.446).

CONCLUSION

Assessing and targeting emptiness may facilitate the reduction of suicide urges in BPD. Future research should investigate treatment strategies for reducing SSI risk among individuals with BPD via targeting emptiness.

What If I Feel Rejected? Borderline Personality, Pathological Narcissism, and Social Rejection in Daily Life

The authors investigate whether and how borderline and pathological narcissistic traits differ in their associations with trait and state rejection sensitivity, and with affective reactions to experiences of social rejection occurring in daily life. Community adults (N = 189) completed baseline measures of rejection sensitivity, borderline personality, and pathological narcissism, and daily measures of perceived social rejection and affective states for 7 days. Vulnerable narcissism was the main driver of negative anticipated emotions for social rejection. Borderline personality made people prone to experiencing social rejection in daily life. Moreover, borderline personality traits predicted greater self-directed aggressive impulses when experiencing social rejection. Grandiose narcissism showed only a negative association with anticipatory anxiety for rejection. These findings highlight that sensitivity to social rejection is crucial in both borderline personality and pathological narcissism.

A systematic review of the relationship between momentary emotional states and nonsuicidal self-injurious thoughts and behaviours

BACKGROUND

Nonsuicidal self-injury (NSSI) is associated with high levels of distress, co-morbid mental health issues, and elevated risk of suicide. Previous literature indicates that emotion regulation is the most endorsed function of NSSI. Experience Sampling Methodology (ESM) provides a powerful tool for investigating the moment-to-moment associations between emotional states and NSSI thoughts and behaviours. The aim of the current study was to systematically review and evaluate ESM research concerning the relationship between momentary emotional states and NSSI.

METHODS

A systematic search of electronic databases from date of inception to 16th April 2021 was conducted. This was supplemented through backwards citation tracking. A risk of bias assessment was completed prior to data synthesis.

RESULTS

Nineteen eligible studies were identified for inclusion in the review. Heightened negative affect was found to typically precede instances of NSSIT thoughts and behaviour. Results were less consistent for positive affect.

LIMITATIONS

Sample sizes across studies were often small, meaningful effect sizes were not always reported, and non-validated measures of NSSI thoughts and behaviour were used during ESM assessments.

CONCLUSIONS

The results support affect regulation models of NSSI, and demonstrate the value of ESM studies, specifically those sampling more than once per day, in plotting the temporal, "in-the-moment" characteristics of these processes.

Sleep irregularity and nonsuicidal self-injurious urges and behaviors

STUDY OBJECTIVES

The objectives of this study were to examine the relationships between sleep regularity and nonsuicidal self-injury (NSSI), including lifetime NSSI history and daily NSSI urges.

METHODS

Undergraduate students (N = 119; 18-26 years), approximately half of whom endorsed a lifetime history of repetitive NSSI, completed a 10-day actigraphy and ecological momentary assessment (EMA) protocol. A Sleep Regularity Index was calculated for all participants using scored epoch by epoch data to capture rapid changes in sleep schedules. Participants responded to EMA prompts assessing NSSI urge severity and negative affect three times daily over the 10-day assessment period.

RESULTS

Results indicate that individuals with a repetitive NSSI history were more likely to experience sleep irregularity than those without a history of NSSI. Findings also suggest that sleep irregularity was associated with more intense urges to engage in NSSI on a daily basis, even after accounting for average daily sleep duration, sleep timing, negative affect, and NSSI history. Neither sleep duration nor sleep timing was associated with NSSI history nor daily NSSI urge intensity.

CONCLUSIONS

Findings suggest that sleep irregularity is linked with NSSI, including NSSI history and intensity of urges to engage in NSSI. The present study not only supports the growing evidence linking sleep disturbance with the risk for self-injury but also demonstrates this relationship using actigraphy and real-time assessments of NSSI urge severity. Findings highlight the importance of delineating the nuances in sleep irregularity that are proximally associated with NSSI risk and identifying targets for intervention.

Predicting Non-Suicidal Self-Injury in Young Adults with and without Borderline Personality Disorder: a Multilevel Approach Combining Ecological Momentary Assessment and Self-Report Measures

Non-suicidal self-injury (NSSI) is an increasingly prevalent phenomenon associated with many detrimental outcomes, ranging from poor academic performance to suicide attempts. Research on self-harming behaviors has identified emotion dysregulation, negative affect, and borderline pathology as strong risk factors of NSSI, whereas the potential protective effects of metacognitive skills such as decentering have not yet been explored. The current study combined ecological momentary assessment (EMA) and self-report measures to explore potential risk and protective factors of NSSI in a clinical group of Borderline Personality Disorder (BPD) patients with NSSI (N = 22), a subclinical group of college students with NSSI (N = 19), and a non-clinical healthy control group (N = 23). Participants completed self-report measures of borderline pathology, emotion dysregulation, decentering ability, and negative emotional symptoms, and they used the Sinjur App (EMA instrument) at least three times a day for 15 days to capture negative affect and NSSI in daily life. A multilevel mixed-effect regression analysis with both self-report and EMA measures was conducted to identify predictors of NSSI. The multilevel analysis showed that only momentary frustration directly predicted NSSI. Momentary guilt and anger only predicted NSSI when interacting with more stable traits of borderline pathology and negative emotional symptoms. Most importantly, greater decentering capacity protected against self-injury and attenuated the association between momentary sadness and NSSI. Findings contribute novel knowledge about NSSI, documenting the protective effects of decentering and highlighting the benefit of interventions that target metacognitive emotion regulation skills.

Emotional response inhibition to self-harm stimuli interacts with momentary negative affect to predict nonsuicidal self-injury urges

The current study investigated whether impaired emotional response inhibition to self-harm stimuli is a risk factor for real-time nonsuicidal self-injury (NSSI) urges. Participants were 60 university students with a history of repetitive NSSI. At baseline, participants completed an emotional stop-signal task assessing response inhibition to self-harm stimuli. Participants subsequently completed an ecological momentary assessment protocol in which they reported negative affect, urgency, and NSSI urge intensity three times daily over a ten-day period. Impaired emotional response inhibition to self-harm stimuli did not evidence a main effect on the strength of momentary NSSI urges. However, emotional response inhibition to self-harm images interacted with momentary negative affect to predict the strength of real-time NSSI urges, after adjusting for emotional response inhibition to neutral images. Our findings suggest that emotional response inhibition deficits specifically to self-harm stimuli may pose vulnerability for increased NSSI urge intensity during real-time, state-level negative affect.