Self-harming behavior in incarcerated male delinquent adolescents

Nonsuicidal Self-Injury and Suicide: Differences Between Those With and Without Borderline Personality Disorder

Nonsuicidal self-injury (NSSI) is associated with borderline personality disorder (BPD), but it also occurs in nonclinical samples (Briere & Gil, 1998), inflicting serious harm and serving as a precursor to suicide attempts (Klonsky, May, & Glenn, 2013). Therefore, the DSM-5 proposed a nonsuicidal self-injury disorder (NSSID) and suicidal behavior disorder. Because this addition requires reconciliation with current BPD criteria, the authors' study evaluated type and frequency of NSSI and suicide attempts in 3,795 outpatients. Both were found in those without BPD, although the behaviors increased when some symptoms and full criteria for BPD were met. Wound/skin picking, scratching, and hitting were most common. Cutting was the fifth most common self-injury for those with BPD and the eighth most common for those without the disorder. Therefore, increased clinical attention is warranted for such self-injury, which may go unnoticed but indicate significant distress. Findings suggest that NSSID/suicidal behavior disorder may account for self-injury outside of BPD.

Psychopathology and Borderline Personality Pathology Associated with Lifetime Self-Injurious Behavior in Adolescent Psychiatric Inpatients and Detainees

OBJECTIVE

Self-injurious behavior (SIB) is a widespread phenomenon among adolescent psychiatric inpatients. It is also reported among delinquent adolescents detained in correctional facilities. While previous studies have addressed different functions of SIB within offender populations, here we investigate particular patterns of borderline personality pathology and psychopathology underlying SIB in both adolescent psychiatric inpatients and detainees.

METHOD

Adolescent psychiatric inpatients and detainees were recruited consecutively. Participants completed self-reports on SIB, suicidal thoughts and behavior, borderline personality pathology, and general psychopathology. Predictors of lifetime SIB by group were analyzed.

RESULTS

Psychiatric inpatients (n = 77) and detainees (n = 50) did not differ with respect to lifetime SIB (57.14 % versus 54.00 %), whereas SIB within the past year did (67.53 % versus 14 %; χ2₍₁₎ = 6.158, p = .013). Psychiatric inpatients reported greater emotional problems (t₍₁₂₅₎ = 5.109, p < .0001) and greater borderline personality pathology. Those with lifetime SIB were characterized by greater emotional problems and borderline personality pathology, independent of their group. Results from regression analyses suggest no group-specific predictors of lifetime SIB.

CONCLUSIONS

Although psychiatric inpatients endorse greater psychopathological distress, lifetime SIB among adolescent psychiatric inpatients and detainees is associated with similar patterns of psychopathology and borderline personality pathology.

Nonsuicidal self-injury: relationship to behavioral and self-rating measures of impulsivity and self-aggression

Previous research using self-report measures has shown an association between nonsuicidal self-injurious behavior (NSSI) and impulsive tendencies. However, self-injurers have not been shown to be different from comparison groups on laboratory tasks putatively assessing impulsive behavior. One explanation for these contradictory findings is that self-report and laboratory measures of impulsive behavior tap into distinct but related constructs. Moreover, performance on laboratory measures of impulsive behavior can be influenced by myriad contextual and affective factors not present during past self-reported NSSI events. Accordingly, a relationship between behavioral tasks of impulsivity and self-injurious behavior could emerge if both are assessed relatively close in time under controlled laboratory conditions. To test this possibility, both self-ratings and laboratory task measures of self-injurious and impulsive behavior were employed in the current study. This multi-modal assessment approach revealed that self-rated impulsivity was associated with both self-report and behavioral measures of self-injurious behavior. Moreover, behavioral measures of impulsivity were associated with self-injurious behavior, but not NSSI history. These results provide support for the notion that a multi-modal approach to assessing self-injurious behavior is important for better understanding the correlates of nonsuicidal self-injury.

Giving up self-injury: a comparison of everyday social and personal resources in past versus current self-injurers

Self-injury represents a common yet perplexing set of behaviors, considered difficult to treat. The current study aimed to identify social and personal resources that may aid in cessation of self-injury. A community sample of 312 participants completed an online questionnaire. In line with Brown and Williams ( 2007 ), we compared all self-injurers (current and past) (106, 34%) with those who had never self-injured (206, 66%), and then current (38, 12.2%) with past self-injurers (68, 21.8%). Overall, self-injurers reported significantly lower levels of perceived social support, social connectedness, resilience, self-esteem, and life satisfaction compared to those with no such history. Further analysis indicated that family support, self-esteem, resilience, and satisfaction with life were significantly better for past compared to current self-injurers (at the p < 0.01 level). Logistic regression suggested that self-injurers could be distinguished from non self-injurers on Self-esteem and Social Connectedness. A further logistic regression suggested that past self-injurers could be distinguished from current self-injurers by their level of Resilience. The research has important preventive and clinical implications.

Are the "worst of the worst" self-injurious prisoners more likely to end up in long-term maximum-security administrative segregation?

This study examined the association of extent of prisoner self-injurious behavior (SIB) and placement in long-term maximum-security administrative segregation. A prisoner subgroup (n=132) defined by extent of SIB was matched by conviction prefix and security level to a group of prisoners who had never engaged in SIB (n=132) and compared on selected variables. Relative to prisoners who either engaged in less extensive SIB or none at all, prisoners who engaged in three or more forms of SIB while in prison were found to be twice as likely to be housed in long-term administrative segregation, less educated, began their criminal careers at an earlier age, engaged in more violence in the community and in prison, involved in property destruction, and experienced a much greater degree of housing instability in prison.

Positive attitudes and self-harming behavior of adolescents in a juvenile detention house in Taiwan

This study aimed to evaluate the less stigmatizing positivity construct screening measurement and its association with recent self-harming behaviors among adolescents. Participants were 193 detained Taiwanese adolescents. Questionnaires consisted of a deliberate self-harm inventory, a positivity construct measurement, a depression scale, data concerning risky health behaviors and demographics. The prevalence rate of recent self-harming behavior among adolescents in the detention house was 43.5%. The logistic model showed that age, gender and level of positivity demonstrated significant odds ratios for self-harm behavior. Results showed that younger age and female gender increased self-harming behavior. In addition, low score on positivity construct screening measurement increased the probability of self-harming behavior. Furthermore, these adolescents also engaged in risky health behaviors and were more depressed. Parental and school awareness for these risky behaviors should be enhanced and appropriate early interventions implemented to prevent negative health outcomes.

Clinical characteristics of self-mutilating behavior in Turkish male subjects with antisocial personality disorder: relationship to psychopathy

AIMS

The aims of this study were to determine the characteristics of self-mutilation (SM) and examine the relationship between SM and psychopathy in male subjects with antisocial personality disorder (APD).

METHODS

APD diagnosis was established by the Structured Clinical Interview for DSM-III-R Axis II Disorders. Subjects (N = 116) were assessed using the Psychopathy Checklist-Revised and a semi-structured self-mutilation questionnaire form.

RESULTS

In males with APD, the percentages of psychopathy and SM were 48.3% (N =56) and 96.6% (N = 112), respectively. There were positive correlations between severity of psychopathy and severity, number, and frequency of SM.

CONCLUSION

Considerably high rates of SM and psychopathy were found in Turkish males with APD. The features of SM were associated with comorbidity of psychopathy. These results showed the importance of exploring the self-injurious behavior and psychopathy when diagnosed with APD.

Juvenile suicide in confinement--findings from the first national survey

Findings from the first national survey on juvenile suicide in confinement are provided, and include the extent and distribution of juvenile suicides, as well as descriptive data on demographic characteristics of each victim, incident, and juvenile facility which sustained the suicide. Among the significant findings were that suicides were evenly distributed, i.e., the same number of deaths occurred within the first few days of confinement as occurred over many months of confinement; most deaths occurred during traditional waking hours; a strong association between room confinement and suicide was found, and no relationship between intoxication and suicide was found. Suicide prevention resources were found to be particularly lacking in juvenile detention centers that experienced suicides.

A critical review of explanatory models for self-mutilating behaviors in adolescents

The present paper presents critical reviews of studies that have explored models of adolescent self-mutilation. Current definitional problems were addressed, as well as a proposal for a classification system of self-mutilation. Seven historically significant explanatory models were included, the sexual/sadomachistic model, the depersonalization model, the interpersonal/systemic model, the suicide model, the physiological/biological model, the affect regulation model, and the behavioral/environmental model. Each model was briefly described, and studies were critiqued according to methodology, research design, and basis upon which authors provided support or rejection of a model. Suggestions for improvement in the literature were made throughout the paper. Studies often overlapped within the models, and the strongest empirical support was shown for the behavioral/environmental model, which included components of the affect regulation model, interpersonal/systemic model, and depersonalization model. Explaining adolescent self-mutilation is a complex task, and evidence provided in this paper suggests that aspects of several models, or an integration of models, likely contribute to the understanding of this phenomenon.

Characteristics and functions of non-suicidal self-injury in a community sample of adolescents

BACKGROUND

Few studies have investigated non-suicidal self-injury (NSSI), or the deliberate, direct destruction of body tissue without conscious suicidal intent, and the motivations for engaging in NSSI among adolescents. This study assessed the prevalence, associated clinical characteristics, and functions of NSSI in a community sample of adolescents.

METHOD

A total of 633 adolescents completed anonymous surveys. NSSI was assessed with the Functional Assessment of Self-Mutilation (FASM).

RESULTS

Some form of NSSI was endorsed by 46.5% (n=293) of the adolescents within the past year, most frequently biting self, cutting/carving skin, hitting self on purpose, and burning skin. Sixty per cent of these, or 28% of the overall sample, endorsed moderate/severe forms of NSSI. Self-injurers reported an average of 12.9 (s.d.=29.4) incidents in the past 12 months, with an average of 2.4 (s.d.=1.7) types of NSSI used. Moderate/severe self-injurers were more likely than minor self-injurers, who in turn were more likely than non-injurers, to have a history of psychiatric treatment, hospitalization and suicide attempt, as well as current suicide ideation. A four-factor model of NSSI functions was indicated, with self-injurers likely to endorse both reasons of automatic reinforcement and social reinforcement. The most common reasons for NSSI were 'to try to get a reaction from someone', 'to get control of a situation', and 'to stop bad feelings'.

CONCLUSIONS

Community adolescents reported high rates of NSSI, engaged in to influence behaviors of others and to manage internal emotions. Intervention efforts should be tailored to reducing individual issues that contribute to NSSI and building alternative skills for positive coping, communication, stress management, and strong social support.

The functions of deliberate self-injury: a review of the evidence

Deliberate self-injury is defined as the intentional, direct injuring of body tissue without suicidal intent. The present article reviews the empirical research on the functions of self-injury. This literature includes self-reports of reasons for self-injuring, descriptions of the phenomenology of self-injury, and laboratory studies examining the effects of self-injury proxies on affect and physiological arousal. Results from 18 studies provide converging evidence for an affect-regulation function. Research indicates that: (a) acute negative affect precedes self-injury, (b) decreased negative affect and relief are present after self-injury, (c) self-injury is most often performed with intent to alleviate negative affect, and (d) negative affect and arousal are reduced by the performance of self-injury proxies in laboratory settings. Studies also provide strong support for a self-punishment function, and modest evidence for anti-dissociation, interpersonal-influence, anti-suicide, sensation-seeking, and interpersonal boundaries functions. The conceptual and empirical relationships among the different functions remain unclear. Future research should address the measurement, co-variation, clinical correlates, and treatment implications of different functions.

Deliberate self-harm and suicide attempt in custody: distinguishing features in male inmates' self-injurious behavior

Self-injurious behavior involving deliberate self-harm and suicide attempts by inmates while under custodial authority is a major problem for prisons and jails (prevalence, legal obligation for suicide prevention, and stress for officers). The differentiation of "serious" vs. "non-serious" and often manipulative suicide attempts as distinct phenomena, each with its own clinical features, is controversially discussed in current literature and a challenge for every diagnostician. If distinct clinical presentations and histories can be observed, an estimation of the seriousness of each act of self-injurious behavior can be simplified, whereby appropriate treatment of the individual case becomes possible. The aim of the study was to find differences between self-injurious behavior of "low seriousness" (i.e. low lethality and low suicidal intent) and of "high seriousness". Therefore, inmates showing self-injurious behavior were divided into subgroups of deliberate self-harm and suicide attempters on the basis of the act's intent and lethality. This was followed by a comparison of the clinical presentations of the individual inmates constituting the subgroups. Hence, 49 inmates showing self-injurious behavior were interviewed and tested with a variety of instruments (SCID-I and II, PCL-R, BDI-II, BHS, BSS, SIS, etc.), and their prison and health files were examined. The results indicate significant correlations between seriousness and some demographic, prison-related variables as well as different measures of depression. Negative, but nonsignificant correlations could be observed with regard to cluster B personality disorders. The PCL-R total score as well as PCL-R factor 1 showed a statistical trend for negative correlations with measures of seriousness. Inmates showing deliberate self-harm and suicide attempters seem to differ in a number of ways. Implications on how the individual prisoner should be treated are discussed.

Self-injurious behavior in human and non-human primates

A review of the literature on human and non-human animal self-injury reveals that there has been little cross-fertilization of ideas between these two domains. Each body of research offers particular strengths, which, if combined, may more keenly inform clinicians and researchers alike about the nature of human self-injury. While research on self-injury among humans has necessarily relied upon correlational designs, researchers who study self-injury among non-human primates have more tightly controlled experimental methods at their disposal. Experimental research allows researchers and clinicians to address issues of causality in ways that are not possible with correlational designs. Despite the difficulties of drawing inferences from different species, a review of the experimental data on non-human primate self-injury may give researchers fresh insights into the elusive nature of human self-injury. This article highlights the research and theoretical material pertaining self-injury and identifies ways in which animal models of self-injury might inform research and clinical understanding of human self-injury.

The developmental psychopathology of self-injurious behavior: compensatory regulation in posttraumatic adaptation

This article utilizes a developmental psychopathology framework to explicate one pathway, originating in childhood traumatic experience, toward the development of self-injurious behavior (SIB). The descriptive psychopathology of SIB is summarized first, followed by an overview of theoretical interpretations of SIB within psychoanalytic, neo-analytic, behavioral, and biological paradigms. Building on these empirical and theoretical foundations, a developmental psychopathology framework is used to model the development of SIB in the aftermath of childhood traumatic experience, particularly maltreatment. In this model, maltreatment undermines positive adaptation at motivational, attitudinal, instrumental, emotional, and/or relational levels of competence. In turn, vulnerabilities in the child's adaptive resources necessitate the application of alternative regulatory and relational strategies, such as self-injury, to the negotiation of contemporaneous and prospective developmental issues. The article concludes with a discussion of the empirical and clinical implications of a developmental understanding of SIB as a compensatory regulatory strategy in posttraumatic adaptation.

Suicide attempts and self-mutilative behavior in a juvenile correctional facility

OBJECTIVE

To determine the lifetime history of suicide attempts in incarcerated youths and psychological factors related to suicidal and self-mutilative behaviors during incarceration.

METHOD

A 25% systematic random sample chart review of adolescents admitted to a juvenile correctional facility yielded a sample of 289 adolescents. Seventy-eight of these adolescents were clinically referred for psychiatric assessment. Suicidal behavior was assessed with the Spectrum of Suicidal Behavior Scale and self-mutilation with the Functional Assessment of Self-Mutilation.

RESULTS

Of the 289 adolescents, 12.4% reported a prior suicide attempt. Almost 60% of these attempts were made using violent methods (e.g., cutting). Of the 78 clinically referred subjects, 30% reported suicidal ideation/behavior and 30% reported self-mutilative behavior while incarcerated. Suicidal clinically referred adolescents reported more depression, anxiety, and anger than nonsuicidal youths. Adolescents who reported self-mutilative behavior had higher anxiety, anger, and substance use than non-self-mutilative adolescents.

CONCLUSIONS

Results suggest that incarcerated adolescents have higher rates of suicide attempts and use more violent methods of attempt than adolescents in the general population. Furthermore, incarcerated clinically referred suicidal and self-mutilative youths report more severe affective symptoms than their nonsuicidal and non-self-mutilative counterparts, suggesting a need for mental health treatment.

Self-mutilative behavior in adolescents who attempt suicide by overdose

OBJECTIVE

To examine the cognitive/affective and behavioral symptoms of adolescent suicide attempters with self-mutilative behavior (SMB).

METHOD

Adolescents evaluated after a suicide attempt that occurred between 1996 and 2000 were divided into two groups: suicide attempters with a history of SMB (n = 52) and suicide attempters without SMB (n = 43). The groups were then compared on psychiatric diagnosis, suicide intent, depression, hopelessness, loneliness, anger, reckless behavior, substance use, and family functioning.

RESULTS

Carving on the skin and picking at a wound were the most commonly reported SMBs, occurring in about one third of the sample. The SMB group was significantly more likely to be diagnosed with oppositional defiant disorder, major depression, and dysthymia and had higher scores on measures of hopelessness, loneliness, anger, risk taking, reckless behavior, and alcohol use than did the non-SMB group. Loneliness increased the odds of SMB almost 6-fold.

CONCLUSIONS

Adolescent suicide attempts with SMB are associated with greater cognitive/affective and behavioral symptoms. Adolescent suicide attempters should be routinely screened for SMB.

Serum cholesterol, suicidal tendencies, impulsivity, aggression, and depression in adolescent psychiatric inpatients

BACKGROUND

This study was undertaken to examine the relationship between serum cholesterol levels and suicidal behaviors in adolescent psychiatric inpatients. Any association between serum cholesterol and measures of suicidal behavior, impulsivity, aggression, anxiety, and depression was also examined.

METHODS

Consecutive admissions (n = 152) to an adolescent psychiatric inpatient unit were assessed using measures of suicidal behavior, violence, impulsivity, and depression. Serum cholesterol was compared between those admitted for reasons of suicidal tendencies and those for other reasons. Correlation between serum cholesterol and measures of suicidal behavior, violence, impulsivity, and depression were examined.

RESULTS

Serum cholesterol levels were significantly higher in adolescent patients who were currently suicidal than in nonsuicidal adolescents. Within the suicidal group, but not in the total inpatient group, serum cholesterol correlated negatively with the degree of suicidal behavior. No correlation between serum cholesterol levels and depression, violence, and impulsivity were detected. No significant differences were found in serum cholesterol levels between diagnoses or between suicidal and nonsuicidal patients within each diagnostic group.

CONCLUSIONS

The association between cholesterol and suicidal tendencies remains complex and may depend on several variables within the population studied. Its usefulness as a biologic risk factor in clinical samples remains to be determined.

The functions of self-mutilation

While pathological self-mutilating behavior has been clinically examined for over 65 years, and much of the literature hypothesizes some function for the behavior, there has been little attempt to integrate or differentiate between different functional ideas. This review uses six functional models extracted from the literature to organize a discussion of the multiple functions of self-mutilation, acknowledging the overdetermined nature of the behavior and attempting to understand how self-mutilation can serve multiple functions simultaneously. Contextual information about the definition, prevalence, phenomenology, patient characteristics, associated diagnoses, and associated symptoms of self-mutilation is first presented. Six functional models are then presented: the environmental model, the antisuicide model, the sexual model, the affect regulation model, the dissociation model, and the boundaries model. Support for these models in the empirical and theoretical literature is presented and treatment implications are explored.

The psychopathology of incarcerated self-mutilators

OBJECTIVE

To investigate the symptomatology of severe psychopathology reported by male incarcerated self-multilators.

METHOD

Comparisons were made with a nonmutilating incarcerated group and a nonincarcerated, nonmutilator group.

RESULTS

A distinctive pattern of symptomatology emerged. Self-mutilators evidenced a wide range of elevated scores on general measures of psychological/psychiatric symptoms, particularly depression and hostility. Aspects of hostility that distinguished self-mutilators for other groups included the urge to act out hostile feelings, critical feelings towards others, paranoid feelings of hostility and guilt. Self-mutilators demonstrated substantial problems with substance abuse, particularly alcohol.

CONCLUSION

A pattern of passive-aggressive, schizoid and avoidant personality styles distinguished self-mutilators from other groups.

Antisocial behaviour in adolescent suicide

Antisocial behaviour among adolescent suicide victims (44 males, 9 females) was investigated in a nationwide psychological autopsy study of suicides in Finland. The data were collected through interviews of the victims' relatives and attending health care personnel, and from official records. Antisocial behaviour was reported among 43% of the victims. Separation from parents, parental alcohol abuse and parental violence were common among male victims with antisocial behaviour. Their psychosocial adjustment was poor, and they had experienced severe stressors. Depressive disorders were common among all suicides, but male victims with antisocial behaviour had more often alcohol abuse and comorbid mental disorders compared with victims without antisocial behaviour. The results indicate a strong relatedness between adolescent suicide and antisocial behaviour. Recognition and treatment of manifest mental symptoms and evaluation of suicide risk among adolescents with antisocial behaviour and substance abuse is emphasized. Antisocial symptoms with relatively short duration and not severe enough to meet the criteria for actual antisocial disorders also need to be taken into account.