Direct and indirect self-injury: Is it really all the same?

Alessandra D'Agostino, Marco Boni, Antonella Aportone, Raffaele Pepi, Mario Rossi Monti

Abstract


Nonsuicidal self-injury commonly refers to the direct and deliberate destruction of body tissue without intent to die (e.g., cutting and burning). However, people may also use indirect ways to mistreat or abuse themselves without altering bodily tissue (e.g., eating disorders and substance abuse). The objective of this study is to explore similarities and differences between direct and indirect forms of self-injury in order to see if a psychopathological continuum of self-injurious behaviors can be observed. Participants were adult psychiatric patients presenting: (a) direct (e.g., cutting) and indirect (e.g., eating disorders) self-injury (Group 1); (b) only indirect (e.g., eating disorders) self-injury (Group 2); (c) neither direct nor indirect self-injury (Group 3). A group of healthy controls (Group 4) was also added, reaching a total of 144 participants. Direct self-harming behaviors, eating disorders, personality disorders, and clinical symptoms were assessed. No significant differences were observed between patients with direct and indirect self-harm and patients with only indirect self-harm in any clinical or personality variable, except for histrionic personality disorder. Results support evidence for the hypothesis that direct and indirect self-harm are related behaviors lying on a same psychopathological continuum, even if, on closer inspection, those who engage in NSSI, in addition to indirect self-injury, do seem to have “something more” from a clinical point of view. More research on larger samples is needed.


Keywords


Self-injury; Direct self-injury; Indirect self-injury; Cutting; Eating disorders.

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References


American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author. https://doi.org/10.1176/appi.books.9780890425596

Ammerman, B. A., Jacobucci, R., Kleiman, E. M., Uyeji, L. L., & McCloskey, M. S. (2018). The relationship between nonsuicidal self‐injury age of onset and severity of self‐harm. Suicide and Life‐Threatening Behavior, 48(1), 31-37. https://doi.org/10.1111/sltb.12330

Blasco-Fontecilla, H., Fernández-Fernández, R., Colino, L., Fajardo, L., Perteguer-Barrio, R., & De Leon, J. (2016). The addictive model of self-harming (non-suicidal and suicidal) behavior. Frontiers in Psychiatry, 7(8), 1-7. https://doi.org/10.3389/fpsyt.2016.00008

Brown, R. C., Fischer, T., Goldwich, A. D., Keller, F., Young, R., & Plener, P. L. (2018). #cutting: Non-suicidal self-injury (NSSI) on Instagram. Psychological medicine, 48(2), 337-346. https://doi.org/10.1017/S0033291717001751

Cerutti, R., Presaghi, F., Manca, M., & Gratz, K. L. (2012). Deliberate self-harm behavior among Italian young adults: Correlations with clinical and nonclinical dimensions of personality. American Journal of Orthopsychiatry, 82(3), 298-308. https://doi.org/10.1111/j.1939-0025.2012.01169.x

Chapman, A. L., Gratz, K. L., & Brown, M. Z. (2006). Solving the puzzle of deliberate self-harm: The experiential avoidance model. Behaviour Research and Therapy, 44, 371-394. https://doi.org/10.1016/j.brat.2005.03.005

Cipriano, A., Cella, S., & Cotrufo, P. (2017). Nonsuicidal self-injury: A systematic review. Frontiers in Psychology, 8, 1-14. https://doi.org/10.3389/fpsyg.2017.01946

Claes, L., Klonsky, E.D., Muehlenkamp, J., Kuppens, P., & Vandereycken, W. (2010). The affect- regulation function of nonsocial self-injury in eating disorder patients: which affect states are regulated? Comprehensive Psychiatry, 51, 386-392. https://doi.org/10.1016/j.comppsych.2009.09.001

D’Agostino, A., Pepi, R., Aportone, A., & Rossi Monti, M. (2018). Self-Injurious Thoughts and Behaviors Questionnaire-Nonsuicidal (SITBQ-NS): Development and validation of a revised version of the Self-Injurious Thoughts and Behaviors Interview (SITBI) for the self-assessment of nonsuicidal self-injury. Clinical Neuropsychiatry, 15(6), 344-352.

Derogatis, L.R. (1994). Symptom Checklist-90-R (SCL-90-R): Administration, scoring, and procedures manual. National Computer Systems.

Dohm, F., Striegel-Moore, R., Wilfley, D., Pike, K., Hook, J., & Fairburn, C. (2002). Self-harm and substance abuse in a community sample of black and white binge eating disorder or bulimia. International Journal of Eating Disorders, 32, 389-400.

Duggan, J. M., Toste, J. R., & Heath, N. L. (2012). An examination of the relationship between body image factors and non-suicidal self-injury in young adults: The mediating influence of emotion dysregulation. Psychiatry Research, 206, 256-264. https://doi.org/10.1016/j.psychres.2012.11.016

Dulit, R. A., Fyer, M.R., Leon A.C., Brodsky, B.S., & Frances, A. J. (1994). Clinical correlates of self-mutilation in borderline personality disorder. The American Journal of Psychiatry, 151, 1305-1311. https://doi.org/10.1176/ajp.151.9.1305

Edmondson, A. J., Brennan, C. A., & House, A. O. (2016). Non-suicidal reasons for self-harm: a systematic review of self-reported accounts. Journal of Affective Disorder, 191, 109–117. https://doi.org/10.1016/j.jad.2015.11.043

Faye, P. (1995). Addictive characteristics of the behavior of self-mutilation. Journal of Psychosocial Nursing and Mental Health Services, 33, 36-39.

Favaro, A., & Santonastaso, P. (2000). Self-injurious behaviors in anorexia nervosa. Journal of Nervous and Mental Disease, 188, 537-542.

Favazza, A. R., DeRosear, L., & Conterio, K. (1989). Self-mutilation and eating disorders. Suicide and Life-Threatening Behavior, 19(4), 352-361.

Favazza, A. R., & Rosenthal, R.J. (1993). Diagnostic issues in self-mutilation. Hospital & Community Psychiatry, 44, 134-140. https://doi.org/10.1176/ps.44.2.134

First, M.B., Spitzer, R.L., Gibbon, M., & Williams, J.B.W. (1996). Structured clinical interview for DSM-IV axis I disorders research version (SCID-I). Biometrics Research, New York State Psychiatric Institute.

First, M. B., Gibbon, M., Spitzer, R. L., Williams, J. B. W., & Benjamin, L. S. (1997). Structured clinical interview for DSM-IV Axis II personality disorders (SCID-II). American Psychiatric Press. https://doi.org/10.1007/978-1-4419-1005-9_66

First, M.B. & Gibbon, M. (2004). The Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I) and the Structured Clinical Interview for DSM-IV Axis II Disorders (SCID-II). In: Hilsenroth, M.J., Segal, D.L. (Eds), Comprehensive handbook of psychological assessment, Vol. 2. Personality assessment (pp. 134-143). John Wiley & Sons Inc.

Garner, D. (2004). Eating disorder inventory-3. Psychological Assessment Resources, Inc.

Giannini, M., Pannocchia, L., Dalle Grave, R., & Muratori, F. (2008). Adattamento italiano dell’EDI-3. Eating Disorder Inventory-3. Giunti OS.

Gratz, K.L. (2001). Measurement of Deliberate Self-Harm: preliminary data on the Deliberate Self-harm Inventory. Journal of Psychopathology and Behavioral Assessment, 23, 253-263.

Gratz, K.L., & Roemer, L. (2008). The relationship between emotion dysregulation and deliberate self-harm among female undergraduate students at an urban commuter university. Cognitive Behaviour Therapy, 37, 14-25. https://doi.org/10.1080/16506070701819524

Green, J.D., Hatgis, C., Kearns, J.C., Nock, M.K., & Marx, B. P. (2017). The Direct and Indirect Self-Harm Inventory (DISH): A new measure for assessing high-risk and self-harm behaviors among military veterans. Psychology of Men & Masculinity, 18(3), 208–214.

Gupta, B., & Trzepacz, P.T. (1997). Serious overdoses admitted to a general hospital: comparison with nonoverdose self-injuries and medically ill patients with suicidal ideation. General hospital psychiatry, 19(3), 209-215. https://doi.org/10.1016/s0163-8343(97)00002-9

Herpertz, S., Sass, H., & Favazza, A. (1997). Impulsivity in self-mutilative behavior: psychometric and biological findings. Journal of Psychiatry Research, 31, 451-465. https://doi.org/10.1016/s0022-3956(97)00004-6

Herpertz, S., Steinmeyer, S. M., Marx., D, Oldtmann, A., & Sass, H. (1995). The significance of aggression and impulsivity for self-mutilation behavior. Pharmacopsychiatry, 28(2), 64-72. https://doi.org/10.1055/s-2007-979622

Hilt, L. M., Nock, M. K., Lloyd-Richardson, E. E., & Prinstein, M. J. (2008). Longitudinal study of nonsuicidal self-injury among young adolescents: rates, correlates, and preliminary test of an interpersonal model. The Journal of Early Adolescence, 28(3), 455–469.

Hooley, J. M., & Franklin, J. C. (2018). Why do people hurt themselves? A new conceptual model of nonsuicidal self-injury. Clinical Psychological Science, 6(3), 428-451. https://doi.org/10.1111/j.1467-8721.2009.01613.x

Hooley, J. M., & St. Germain, S.A. (2014). Expanding the conceptualization of Self-Injurious Behavior, in: Nock, M. K. (Ed.), The Oxford Handbook of Suicide and Self-Injury. Oxford University Press.

Karwautz, A., Resech, F., Wöber-Bingöl, C., & Schuch, B. (1996), Self-mutilation in adolescence as addictive behaviour. Weiner Klinische Wochenschrift, 108, 82-84.

Kiekens, G., Hasking, P., Boyes, M., Claes, L., Mortier, P., Auerbach, R. P., ... & Myin-Germeys, I. (2018a). The associations between non-suicidal self-injury and first onset suicidal thoughts and behaviors. Journal of affective disorders, 239, 171-179. https://doi.org/10.1016/j.jad.2018.06.033

Kiekens, G., Hasking, P., Claes, L., Mortier, P., Auerbach, R. P., Boyes, M., ... & Nock, M. K. (2018). The DSM‐5 nonsuicidal self‐injury disorder among incoming college students: Prevalence and associations with 12‐month mental disorders and suicidal thoughts and behaviors. Depression and anxiety, 35(7), 629-637. https://doi.org/10.1002/da.22754

Klonsky, E. D. (2007). The functions of deliberate self-injury: a review of the evidence. Clinical Psychology Review, 27, 226-239. https://doi.org/10.1016/j.cpr.2006.08.002

Klonsky, E. D. (2009). The functions of self-injury in young adults who cut themselves: clarifying the evidence for affect-regulation. Psychiatry Research, 166, 260-268. https://doi.org/10.1016/j.psychres.2008.02.008

Klonsky, E. D., & Glenn, C.R. (2009). Assessing the functions of Non-Suicidal Self-injury: psychometric proprieties of the Inventory of Statements about Self-injury (ISAS). Journal of Psychopathology and Behavioral Assessment, 31, 215-219. https://doi.org/10.1007/s10862-008-9107-z

Liu, R. T., Scopelliti, K. M., Pittman, S. K., & Zamora, A. S. (2018). Childhood maltreatment and non-suicidal self-injury: a systematic review and meta-analysis. The Lancet Psychiatry, 5(1), 51-64. https://doi.org/10.1016/S2215-0366(17)30469-8

Maffei, C., Fossati, A., Agostoni, I., Barraco, A., Bagnato, M., Donati, D., et al. (1997). Interrater reliability and internal consistency of the Structured Clinical Interview for DSM-IV Axis II Personality Disorders (SCID-II), Version 2.0. Journal of Personality Disorders, 11, 279-284. https://doi.org/10.1521/pedi.1997.11.3.279

Modica, F. (2015). Clinical aspects of personality disorder diagnosis in the DSM-5. Mediterranean Journal of Clinical Psychology, 3(1).

Muehlenkamp, J. J., Engel, S. G., Wadeson, A., Crosby, R. D., Wonderlich, S. A., Simonich, H., & Mitchell, J. E. (2008). Emotional state preceding and following acts of non-suicidal self-injury in bulimia nervosa patients. Behaviour Research and Therapy, 47, 83-87. https://doi.org/10.1016/j.brat.2008.10.011

Newbury, J. B., Arseneault, L., Moffitt, T. E., Caspi, A., Danese, A., Baldwin, J. R., & Fisher, H. L. (2018). Measuring childhood maltreatment to predict early-adult psychopathology: comparison of prospective informant-reports and retrospective self-reports. Journal of psychiatric research, 96, 57-64. https://doi.org/10.1016/j.jpsychires.2017.09.020

Nock, M. (2010). Self-Injury. Annual Review of Clinical Psychology, 6, 339-363. https://doi.org/10.1146/annurev.clinpsy.121208.131258

Nock, M.K. (2014). The Oxford handbook of suicide and self-injury. Oxford University Press.

Nock, M. K., & Favazza, A. R. (2009). Nonsuicidal self-injury: Definition and classification. In Nock, M.K (Ed.), Understanding nonsuicidal self-injury. Origins, assessment and treatment (pp.9-18). American Psychological Association.

Nock, M., & Prinstein, M. (2004). A functional approach to the assessment of self-mutilative behavior. Journal of Consulting and Clinical Psychology, 72(8), 885–890. https://doi.org/10.1037/0022-006X.72.5.885

Paul, T., Schroeter, K., Dahme, B., & Nutzungen, D. (2002). Self-injurious behavior in women with eating disorders. American Journal of Psychiatry, 159, 408-411. https://doi.org/10.1176/appi.ajp.159.3.408

Putniņs, A. L. (1995). Recent drug use and suicidal behaviour among young offenders. Drug and Alcohol Review, 14(2), 151-158.

Sansone, R., & Levitt, J. L. (2002). Self-harm behaviors among those with eating disorder: An overview. Eating Disorders, 10, 205-213.

Sarno, I., Preti, E., Prunas, A., & Madeddu, F. (2011). SCL-90-R Symptom Checklist-90-R Adattamento italiano. Giunti OS.

Schaffer, C. B., Carroll, J., & Abramowitz, S. I. (1982). Self-mutilation and the borderline personality. The Journal of nervous and Mental Disease, 170, 468-473.

Sorgi, K.M., Ammerman, B.A., Cheung, J.C., Fahlgren, M.K., Puhalla, A.A., & Michael S. McCloskey, M.S. (2020). Relationships between non-suicidal self-injury and other maladaptive behaviors: Beyond difficulties in emotion regulation, Archives of Suicide Research, 1-22. https://doi.org/10.1080/13811118.2020.1715906

Stein, D., Lilenfeld, L.R., Wildman, P.C., & Marcus, M. D. (2004). Attempted suicide and self-injury in patient diagnosed with eating disorders. Comprehensive Psychiatry, 45, 447-451.

St. Germain, S. A., & Hooley, J. M. (2012). Direct and indirect forms of non-suicidal self-injury: Evidence for a distinction. Psychiatry Research, 197, 78-84. https://doi.org/10.1016/j.psychres.2011.12.050

Swannel, S. V., Martin, G. E., Page, A., Hasking, P., & St John, N.J. (2014). Prevalence of nonsuicidal self-injury in nonclinical samples: systematic review, meta-analysis and meta-regression. Suicide Life Threatening Behavior, 44(3), 273-303. https://doi.org/10.1111/sltb.12070

Taylor, P. J., Jomar, K., Dhingra, K., Forrester, R., Shahmalak, U., & Dickson, J. M. (2018). A meta-analysis of the prevalence of different functions of non-suicidal self-injury. Journal of Affective Disorders, 227, 759-769. https://doi.org/10.1016/j.jad.2017.11.073

Victor, S. E., Glenn, C. R, & Klonsy, E. D. (2011). Is non-suicidal self-injury an “addiction”? A compare of craving in substance use and non-suicidal self-injury. Psychiatry Research, 197, 73-77. https://doi.org/10.1016/j.psychres.2011.12.011

Walsh, C. G., Ribeiro, J. D., & Franklin, J. C. (2018). Predicting suicide attempts in adolescents with longitudinal clinical data and machinelearning. Journal of child psychology and psychiatry, 59(12), 1261-1270. https://doi.org/10.1111/jcpp.12916

Washburn, J. J., Potthoff, L. M., Juzwin, K. R., & Steyer, D. M. (2015). Assessing DSM-5 Nonsuicidal Self-Injury Disorder in a clinical sample. Psychological Assessment, 27, 31-41. https://doi.org/10.1037/pas0000021




DOI: https://doi.org/10.6092/2282-1619/mjcp-2434

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