Presentations text content in Non-Suicidal Self-Injury:
Slide1
Non-Suicidal Self-Injury:Description, Motivations, and Relationship to Suicide
E. David
Klonsky
, PhD
Associate Professor
Department
of Psychology
University of British Columbia
Slide2Non-Suicidal Self-Injury
Common in youth and adolescents
Can be confused for attempted suicide
Has an important relationship to suicide risk
Slide3Agenda
What is Self-Injury
Who
Self-Injures
Why
People Self-Injure
Relationship to Suicide
Slide4A Preliminary Note
What we know (many
many
studies)
What we think (one or two studies)
What we don’t know (no research yet)
Slide5Agenda
What is Self-Injury
Who
Self-Injures
Why
People Self-Injure
Relationship to Suicide
Slide6What is Self-Injury?
Self-inflicted damage to body tissue
Intentional
No suicidal intent
Slide7What is Self-Injury?
Intentional, direct injuring of one’s body tissue without suicidal intent
Also called: non-suicidal self-injury (NSSI), self-mutilation, self-injurious behavior, self-wounding, and deliberate self-harm.
Slide8
What is Self-Injury?
Skin-cutting, burning, scratching, rubbing skin against rough surfaces, interfering with wound healing
Does not include overdosing, eating disorder behaviors, alcohol/substance
use, body piercings/tattoos*
Slide9Variation in Self-Injury
Frequency
Methods
Medical Severity
Contexts
Motivations
Desire/Efforts to Stop
Slide10Agenda
What is Self-Injury
Who
Self-Injures
Why
People Self-Injure
Relationship to Suicide
Slide11Famous Self-Injurers
Princess Diana
Slide12Famous Self-Injurers
Angelina Jolie
Slide13Famous Self-Injurers
Christina Ricci
Slide14Famous Self-Injurers
Drew Barrymore
Slide15Famous Self-Injurers
Johnny Depp
Slide16Famous Self-Injurers
Eminem
Slide17Famous Self-Injurers
Marsha Linehan
Slide18Famous Self-Injurers
Harry Potter’s DobbyKlonsky, E.D. & Laptook, R. (2007). Dobby had to iron his hands, sir! Self-inflicted cuts, burns, and bruises in Harry Potter. In the Psychology of Harry Potter. BenBella Books.
Slide19Who Self-Injures?
Young Adolescents 8%
High-School 14 - 15%
University Students 17%
General Adult Population 4-6%
Adolescent Inpatients 40 - 80%
Klonsky
, E.D. &
Muehlenkamp
, J.J. (2007). Self-injury: A research review for the practitioner. J
ournal of Clinical Psychology: In Session
.
Slide20Psychological Characteristics
Negative
Emotions/Emotion
Dysregulation
Depression
Anxiety
Anger
Self-Directed Negative Emotion
Suicide Ideation and Attempts
Slide21Defining Characteristic
Intense, Self-Directed Negative Emotions
?
Slide22What About Abuse Histories?
“
may be reenacting the abuse perpetrated on them”
(Noll, 2003)
“
manifestation of sexual abuse”
(Cavanaugh, 2002)
Abuse “contributes heavily to the initiation of self-destructive behaviors”
(van der
Kolk
, 1991)
Slide23Child Sex Abuse and Self-Injury
Analysis of 44
studies
Median phi = 0.23 (
small relationship)
Klonsky
, E.D. & Moyer, A. (2008). Childhood sexual abuse and non-suicidal self-injury: Meta-
analysis.
British Journal of Psychiatry.
Slide24Child Sex Abuse and Self-Injury: Conclusion
Abuse histories can contribute to negative emotions driving NSSI, but
…
… many
who self-injure do not have abuse histories, and many with abuse histories
do
not self-injure.
Slide25Agenda
What is Self-Injury
Who
Self-Injures
Why
People Self-Injure
Relationship to Suicide
Slide26Why People Self-Injure: Theories
Theory
Description of Theory
Anti-Dissociation
To end the experience of depersonalization or dissociation
Anti-Suicide
To replace or compromise with the impulse to commit suicide
Emotion Regulation
To alleviate intense negative emotions
Interpersonal Boundaries
To assert one’s identity or a distinction between self and other
Interpersonal Influence
To seek help from or manipulate others
Self Punishment
To derogate or express anger towards oneself
Sensation Seeking
To generate excitement or exhilaration
Sexual
To control, distract from, or gratify uncomfortable sexual urges
Slide27Why People Self-Injure: Research
Sources of evidence
1) Reasons/motivations for self-injury
2) Experience of self-injury
3) Laboratory studies of proxies for self-injury
Klonsky, E.D. (2007). The functions of deliberate self-injury: A review of the evidence.
Clinical Psychology Review.
Slide28Why People Self-Injure: Research
Theory
Evidence For Theory
Anti-Dissociation
R, R, R, r, r, r, P, p,
-
p
Anti-Suicide
R, r, r
Emotion Regulation
R, R, R, R, R, R, R, R, R, R, R, P, P, P, P, P, P, L, L, L
Interpersonal Boundaries
r, r
Interpersonal Influence
R, r, r, r, r, r, r, p, p
Self Punishment
R, R, R, R, R, R, r, r, r, r, r
Sensation Seeking
r, r, r, r, r
Results of 18 studies of reasons [R, r], self-report of phenomenology [P, p], or laboratory data [L, l].
Slide29Why People Self-Injure: Research
Primary sources of evidence
1)
Reasons/motivations for self-injury
2) Experience of self-injury
Klonsky, E.D. (2007). The functions of deliberate self-injury: A review of the evidence.
Clinical Psychology Review.
Slide30Why People Self-Injure: Research
Primary sources of evidence
1)
Reasons/motivations for self-injury
2) Experience of self-injury
Klonsky, E.D. (2007). The functions of deliberate self-injury: A review of the evidence.
Clinical Psychology Review.
Slide31Emotion Regulation
50-95% of self-injurers
“To release emotional pressure that builds up inside me”
“To get rid of intolerable emotions”
“To control how I am feeling”
Klonsky, E.D. (2007). The functions of deliberate self-injury: A review of the evidence.
Clinical Psychology Review.
Slide32Self-Punishment
More than 50% of self-injurers
“To express anger at myself”
“To punish myself”
Klonsky
, E.D. (2007). The functions of deliberate self-injury: A review of the evidence.
Clinical Psychology Review.
Slide33Anti-Suicide
3
rd
most common reason
“To avoid the impulse to attempt suicide”
“To stop suicidal ideation or attempts”
“To stop me from killing myself”
Klonsky, E.D. (2007). The functions of deliberate self-injury: A review of the evidence.
Clinical Psychology Review.
Slide34Anti-Dissociation/Depersonalization
4
rd
most common reason
“To know I am capable of feeling physical pain”
“To feel like myself again”
“To feel real”
Klonsky, E.D. (2007). The functions of deliberate self-injury: A review of the evidence.
Clinical Psychology Review.
Slide35Interpersonal Influence
5
th
most common reason
“To let others know what I am going through”
“To get those around me to understand what I’m going through”
“To get reactions out of people”
Klonsky
, E.D. (2007). The functions of deliberate self-injury: A review of the evidence.
Clinical Psychology Review.
Slide36Sensation/Excitement Seeking
6
th
most common reason
“To feel exhilarated”
“I thought it would be fun”
Klonsky
, E.D. (2007). The functions of deliberate self-injury: A review of the evidence.
Clinical Psychology Review.
Slide37Why People Self-Injure: Research
Primary sources of evidence
1) Reasons/motivations for self-injury
2) Experience of self-injury
Klonsky, E.D. (2007). The functions of deliberate self-injury: A review of the evidence.
Clinical Psychology Review.
Slide38Why People Self-Injure: Research
Primary sources of evidence
1) Reasons/motivations for self-injury
2
) Experience of self-injury
Klonsky, E.D. (2007). The functions of deliberate self-injury: A review of the evidence.
Clinical Psychology Review.
Slide39Emotions and Self-Injury
40
Emotions
Before, During, and After Self-Injury
Examples:
Angry, Sad, Lonely, Frustrated, Worthless, Guilty
Happy, Relieved, Hopeful, Satisfied
Bored, Restless, Apathetic
Unreal, Mesmerized, In a Trance
Klonsky
, E.D. (2009). The functions of self-injury in young adults who cut themselves:
Clarifying the evidence for affect-regulation.
Psychiatry Research
.
Slide40Emotions and Self-Injury
BeforeOverwhelmedSadHurt Emotionally
DuringAngry at SelfHurt EmotionallyIsolated
After
Relieved
Angry at Self
Calm
Slide41Low-Arousal Negative Emotions
Slide42High-Arousal Negative Emotions
Slide43Low-Arousal Positive Emotions
Slide44Big Changes in Negative Arousal
Emotion
Cohen’s
d
Relieved +2.25
Calm +1.39
Overwhelmed - 0.89
Anxious - 0.81
Slide45Why People Self-Injure: Theories
Theory
Description of Theory
Anti-Dissociation
To end the experience of depersonalization or dissociation
Anti-Suicide
To replace or compromise with the impulse to commit suicide
Emotion Regulation
To alleviate intense negative emotions
Interpersonal Boundaries
To assert one’s identity or a distinction between self and other
Interpersonal Influence
To seek help from or manipulate others
Self Punishment
To derogate or express anger towards oneself
Sensation Seeking
To generate excitement or exhilaration
Sexual
To control, distract from, or gratify uncomfortable sexual urges
Slide46Why People Self-Injure: Theories
Theory
Description of Theory
Anti-Dissociation
To end the experience of depersonalization or dissociation
Anti-Suicide
To replace or compromise with the impulse to commit suicide
Emotion Regulation
To alleviate intense negative emotions
Interpersonal Boundaries
To assert one’s identity or a distinction between self and other
Interpersonal Influence
To seek help from or manipulate others
Self Punishment
To derogate or express anger towards oneself
Sensation Seeking
To generate excitement or exhilaration
Sexual
To control, distract from, or gratify uncomfortable sexual urges
Slide47Why People Self-Injure: Theories
Theory
Description of Theory
Anti-Dissociation
To end the experience of depersonalization or dissociation
Anti-Suicide
To replace or compromise with the impulse to commit suicide
Emotion Regulation
To alleviate intense negative arousal
Interpersonal Boundaries
To assert one’s identity or a distinction between self and other
Interpersonal Influence
To seek help from or manipulate others
Self Punishment
To derogate or express anger towards oneself
Sensation Seeking
To generate excitement or exhilaration
Sexual
To control, distract from, or gratify uncomfortable sexual urges
Slide48Why People Self-Injure: Theories
Theory
Description of Theory
Anti-Dissociation
To end the experience of depersonalization or dissociation
Anti-Suicide
To replace or compromise with the impulse to commit suicide
Emotion Regulation
To alleviate intense negative arousal
Interpersonal Boundaries
To assert one’s identity or a distinction between self and other
Interpersonal Influence
To seek help from or manipulate others
Self Punishment
To derogate or express anger towards oneself
Sensation Seeking
To generate excitement or exhilaration
Sexual
To control, distract from, or gratify uncomfortable sexual urges
Slide49Functions of Self-Injury
Organizing conceptual framework
Valid and comprehensive assessment
Slide50Inventory of Statements about Self-injury(ISAS)
Assesses 13 functions of NSSI
Three items per function
39-item measure
Klonsky
, E.D. &
Olino
. T.O. (2008). Identifying clinically distinct subgroups of self-injurers among
young adults: A latent class analysis.
Journal of Consulting and Clinical Psychology
.
Klonsky
, E.D. & Glenn, C.R. (2009). Assessing the functions of non-suicidal self-injury:
Psychometric properties of the Inventory of Statements About Self-injury (ISAS).
Journal of
Psychopathology and Behavioral Assessment.
Slide51
Affect Regulation…calming myself down.Self-Punishment…expressing anger towards myself for being worthless or stupid.Anti-Suicide…putting a stop to suicidal thoughts.Anti-Dissociation…causing pain so I will stop feeling numb.Interpersonal Influence…letting others know the extent of my physical pain.Sensation Seeking…doing something to generate excitement or exhilaration.Peer Bonding…fitting in with others.Self-Care…creating a physical injury that is easier to care for than my emotional distressMarking Distress…creating a physical sign that I feel awful.Interpersonal Boundaries…creating a boundary between myself and others.Toughness…seeing if I can stand the pain.Revenge…getting back at someone.Autonomy…demonstrating I do not need to rely on others for help.
Sample I-SAS items
“When I harm myself, I am…
Slide52Inventory of Statements about Self-injury(ISAS)
235 self-injurers from a college sample
18-19 yrs old, 57% female, 42% Caucasian
Hitting self, biting, cutting, pinching, wound-picking
Slide53ISAS Factor loadings (Exploratory Factor Analysis with Promax Rotation)
Function
Mean (SD)
Social Functions
Intrapersonal Functions
Affect Regulation
Anti-Dissociation
Anti-Suicide
Marking Distress
Self-Punishment
Autonomy
Interpersonal Boundaries
Interpersonal Influence
Peer Bonding
Revenge
Self-Care
Sensation Seeking
Toughness
3.0 (2.1)
1.0 (1.6)
0.8 (1.5)
1.5 (1.8)
2.0 (2.1)
0.6 (1.3)
0.8 (1.4)
0.8 (1.4)
0.5 (1.3)
0.6 (1.4)
0.8 (1.4)
0.7 (1.3)
1.0 (1.4)
-.14
.21
. 35
.04
-.14
.64
.52
.54
.98
.53
.41
.87
.65
.69
.50
.42
.82
.84
.11
.26
.23
-.26
.16
.33
-.18
.02
Slide54ISAS Factor loadings (Exploratory Factor Analysis with Promax Rotation)
Function
Mean (SD)
Social Functions
Intrapersonal Functions
Affect Regulation
Anti-Dissociation
Anti-Suicide
Marking Distress
Self-Punishment
Autonomy
Interpersonal Boundaries
Interpersonal Influence
Peer Bonding
Revenge
Self-Care
Sensation Seeking
Toughness
3.0
(2.1)
1.0 (1.6)
0.8 (1.5)
1.5 (1.8)
2.0
(2.1)
0.6 (1.3)
0.8 (1.4)
0.8 (1.4)
0.5 (1.3)
0.6 (1.4)
0.8 (1.4)
0.7 (1.3)
1.0 (1.4)
-.14
.21
. 35
.04
-.14
.64
.52
.54
.98
.53
.41
.87
.65
.69
.50
.42
.82
.84
.11
.26
.23
-.26
.16
.33
-.18
.02
Slide55Relationship of Functions to NSSI Frequency
NSSI Behavior
Social Functionsα = .87 Intrapersonal Functionsα = .80CuttingNeedle stickingCarvingBanging/Hitting self.19.30.19.18.13
Note.
All correlations are statistically significant at an alpha of .03.
Slide56Relationship of Functions to Cutting
Correlation with Cutting
Affect RegulationAnti-DissociationAnti-Suicide Marking DistressSelf-PunishmentAutonomyInterpersonal BoundariesInterpersonal InfluencePeer BondingRevengeSelf-CareSensation SeekingToughness.21.24.24.23.22.04.04.15-.01.09.04.06.11
Note.
Correlations above .20 are statistically significant at an alpha of .001.
Slide57Relationship of Functions to Clinical Variables
Clinical Variable
Social Functionsα = .87 Intrapersonal Functionsα = .80DepressionAnxietyBorderline Personality Disorder.24.33 .14 .42*.36 .43*
Note.
Correlations above .16 are statistically significant an at alpha level of .01.
* Indicates correlations are significantly different at an alpha of .01.
Slide58Relationship of Functions to Clinical and Contextual Variables
Clinical/Contextual Variable
Social Functionsα = .87 Intrapersonal Functionsα = .80Suicidal IdeationSuicide PlansAttempted Suicide .10 .14 .12 .32* .33* .29*
Note.
Correlations above .16 are statistically significant an at alpha level of .01.
* Indicates correlations are significantly different at an alpha of .01.
Slide59ISAS in Alexian Brothers Hospital
108 psychiatric patients
Ages 11 – 62, mean=19
90% female
72% Caucasian
Slide60Function
Social
Intrapersonal
Affect Regulation
.77
Anti-Dissociation
.62
Anti-Suicide
.50
Marking Distress
.75
Self-Punishment
.67
Autonomy
.55
Interpersonal Boundaries
.44
Interpersonal Influence
.51
Peer Bonding
.95
Revenge
.47
Self-Care
.39
.41
Sensation Seeking
.71
Toughness
.37
.43
Slide61ISAS in an Adolescent Psychiatric Sample
80 psychiatric patients with NSSI from South Oaks Hospital in Long Island, NY
Mean age = 15 (12 - 18)
70% female
61% Caucasian
Slide62Function
Social
Intrapersonal
Affect Regulation
.87
Anti-Dissociation
.83
Anti-Suicide
.66
Marking Distress
.63
Self-Punishment
.77
Autonomy
.79
Interpersonal Boundaries
.69
Interpersonal Influence
.54
Peer Bonding
.77
Revenge
.70
Self-Care
.36
.37
Sensation Seeking
.73
Toughness
.72
Slide63FASM in Alexian Brothers Sample
Item
Social
Intrapersonal
Receive more attention (S-P)
.83
Get a reaction (S-P)
.75
Feel more a part of a group (S-P)
.74
Get parents to notice (S-P)
.72
Get attention (S-P)
.64
Avoid something unpleasant (S-N)
.63
Avoid school/work/activities (S-N)
.55
Stop bad feelings (I-N)
.68
Feel something (I-P)
.68
Relive feeling numb/empty (I-N)
.64
Punish self (I-P)
.58
Feel relaxed (I-P)
.54
Slide64Two Motivational Dimensions
1. Self-Focused
2. Other-Focused
Slide65Two Motivational Dimensions
1. Self-Focused
2. Other-Focused
Affect
Regulation
Anti-Dissociation
Anti-Suicide
Marking Distress
Self-Punishment
Slide66Two Motivational Dimensions
1. Self-Focused
2. Other-Focused
Affect
Regulation
Interpersonal
Influence
Anti-Dissociation
Peer Bonding
Anti-Suicide
Revenge
Marking Distress
Excitement Seeking
Self-Punishment
Toughness
Slide67Two Motivational Dimensions
1. Self-Focused
2. Other-Focused
More Self-Injury
More Psychopathology
More
Suicidality
Slide68NSSI Motivations: Summary
Most common
motivations are
emotion regulation and self-punishment
NSSI
motivations fall
into two super-ordinate dimensions:
1)
self-focused and
2)
other-focused
Self-focused motivations are
associated with greatest clinical severity
Slide69Agenda
What is Self-Injury
Who
Self-Injures
Why
People Self-Injure
Relationship to Suicide
Slide70NSSI vs. Attempted Suicide
Differ in terms of intent and medical severity
Commonly co-occur
Avoid oversimplified conclusions!
Complex relationship needs careful study
Slide71NSSI vs. Attempted Suicide
NSSI
sometimes mistaken for attempted
suicide
Unnecessary hospitalizations
Harms
case
conceptualization
Misallocates
valuable
resources
NSSI conveys valuable information regarding suicide risk
Results from 4 Studies:
Does NSSI predict attempted suicide?
Slide72Predictors of Attempted Suicide139 Adolescent Psychiatric Inpatients
Suicide Ideation .55
NSSI .50
Borderline Personality Disorder .
37
Depression
.20
Anxiety .16
Impulsivity .11
Slide73Predictors of Attempted Suicide426 High-School Students
Suicide Ideation .51
NSSI .
38
Borderline Personality Disorder .29
Depression
.
24
Anxiety .18
Impulsivity
.11
Slide74Predictors of Attempted Suicide1,351 Undergraduates
Suicide Ideation
.44
NSSI
.28
Borderline Personality Disorder .
22
Depression .24
Anxiety .16
Impulsivity
.10
Slide75Predictors of Attempted Suicide438 United States Adults
Suicide Ideation .36
NSSI .34
Slide76Summary of Results From Four Studies
NSSI relates to attempted suicide
NSSI relates to attempted suicide more strongly than other risk-factors
NSSI is similar to suicide ideation in conferring risk for suicide
Yet, like suicide ideation, many/most who engage in NSSI have not attempted suicide
Slide77??
Why does NSSI have such a strong relationship to attempted suicide?
Thomas Joiner’s
Interpersonal-Psychological Theory
Desire + Capability
Suicide
Slide78??
Most risk factors only confer desire
Depression
Hopelessness
Suicidal ideation
Others only confer capability
Access to lethal means
Combat exposure in military
Slide79??
NSSI confers both desire
and
capability
Desire (intense negative emotions)
Capability
(habituation to self-inflicted violence)
(Nock et al., 2006)
NSSI is relatively unique among risk-factors in that it represents
double-trouble
!
Slide80So what have we learned?
Is NSSI a form of suicidal behavior?
No!
Is NSSI unrelated to attempted suicide?
No!
NSSI is different from attempted suicide, but
confers strong suicide risk because it represents
double-trouble
(both desire + capability)
Slide81Suicide: Take-Home Message
NSSI is not attempted
suicide, but…
…
P
eople
who self-injure are at greater risk for suicidal ideation
… People who
self-injure are more capable of acting on
suicidal
thoughts
Slide82For more information…
Published 2011
User-friendly information for health professionals
Slide83Thank you
Graduate Students
Catherine Glenn
Alexis May
Sarah Victor
Anita
Hibbert
Funding Sources
National Institute of Mental Health
American Foundation for Suicide Prevention
Stony Brook University Center for Survey Research
Slide84Thank you!!
Questions, Comments,
Discussion??
Slide85Extra Slides
Slide86NSSI and BPD
DSM-IV: NSSI is part of a BPD criterion
DSM-5: NSSI proposed as own diagnostic entity
What exactly is the relationship of NSSI to BPD?
Slide87What BPD and NSSI Share
Frequently co-occur
Both have emotion
dysregulation
as a core
feature
Both associated with shame
Slide88Can NSSI be Distinct from BPD?
198 Adolescent Psychiatric Inpatients
Average of 3.3 Axis-I diagnoses
Two Key Questions
:
Does BPD overlap with NSSI more than with other disorders?
Does NSSI overlap with BPD more than with other disorders?
Slide89Of those with BPD…
… 78% NSSI
… 84% Anxiety Disorder
… 84% Disruptive Behavior Disorder (ODD or Conduct)
… 78% Mood Disorder
Slide90Of those with NSSI…
… 52% BPD
… 74% Anxiety Disorder
… 73% ADHD
… 66% Mood Disorder
Slide91NSSI and BPD: Conclusions
NSSI and BPD are correlated, but …
Many who have BPD do not self-injure
Many who self-injure do not have BPD
Slide92Clinical Take-Home Message
Diagnosis of BPD is not implied by presence of NSSI, but made through careful assessment on a case-by-case
basis.
Think of BPD and NSSI as you do Depression and
Suicidality
…
… they often co-occur and even contribute to one another, yet are best view as distinct phenomena
Slide93Agenda
What is Self-Injury
Who
Self-Injures
Why
People Self-Injure
Key
Clinical Issues
:
Borderline Personality Disorder
DSM-5
Suicide
Slide9494
A Distinct NSSI Diagnosis?
A symptom of a personality disorder in DSM-IV
Proposed as a Behavioral Disorder for DSM-V
Slide9595
The Process
Group of Experts
Members from Mood Disorders and Child/Adolescent Disorders Workgroups
Advisors with particular expertise in NSSI
Lots of phone and email discussions
Separateness
Independent Clinical
S
ignificance
Threshold
Defining Characteristics
Differentiation from other Behaviors/Disorders
Slide96And the proposed NSSI diagnosis is ………..
…not going to take effect in DSM-5
… but will appear in DSM-5 appendix as a research diagnosis
Slide97A. In the last year, the individual has, on 5 or more days, engaged in intentional self-inflicted damage to the surface of his or her body, of a sort likely to induce bleeding or bruising or pain (e.g., cutting, burning, stabbing, hitting, excessive rubbing), for purposes not socially sanctioned (e.g., body piercing, tattooing, etc.), but performed with the expectation that the injury will lead to only minor or moderate physical harm. The absence of suicidal intent is either reported by the patient or can be inferred by frequent use of methods that the patient knows, by experience, not to have lethal potential. (When uncertain, code with NOS 2.) The behavior is not of a common and trivial nature, such as picking at a wound or nail biting.B. The intentional injury is associated with at least 2 of the following: 1. Negative feelings or thoughts, such as depression, anxiety, tension, anger, generalized distress, or self-criticism, occurring in the period immediately prior to the self-injurious act. 2. Prior to engaging in the act, a period of preoccupation with the intended behavior that is difficult to resist. 3. The urge to engage in self-injury occurs frequently, although it might not be acted upon. 4. The activity is engaged in with a purpose; this might be relief from a negative feeling/cognitive state or interpersonal difficulty or induction of a positive feeling state. The patient anticipates these will occur either during or immediately following the self-injury.
97
Slide98Agenda
What is Self-Injury
Who
Self-Injures
Why
People Self-Injure
Key
Clinical Issues
:
Borderline Personality Disorder
DSM-5
Suicide
Slide99Some Overall Clinical Conclusions
Treatment should emphasize
Functions (functional assessment)
Negative Emotions (emotion regulation skills)
Self-criticism (cognitive techniques)
Arousal regulation (exercise?)
Careful Diagnosis
Suicidality
should be carefully monitored
Slide100Choose your own adventure
Why do people choose NSSI and not something else? (role of self-derogation/criticism)
Physiologically speaking, how does NSSI work?
Is NSSI an ‘addictive’ behavior?
Why is physical pain reduced in NSSI?
Slide101Many ways to cope with negative emotions …
why self-injury?
Slide102Self-Derogation
Self-injurers consistently score high on measures of self-
derogation, self-criticism, and low self-esteem
Klonsky, Oltmanns, & Turkheimer, 2003,
American Journal of Psychiatry
; Klonsky & Muehlenkamp, 2007,
Journal of Clinical Psychology/In Session
; Glassman et al., 2007,
Behaviour Research and Therapy
)
Self-punishment/self-directed anger is the second most
common motivation for self-injury
(Klonsky, 2007,
Clinical Psychology Review
)
“To express anger at myself”
(Klonsky, 2009,
Psychiatry Research
)
Slide103NESD Theory
For those high in negative emotionality (NE)
and
self-derogation (SD) …
… Self-injury is an ego-syntonic regulation method
… Self-injury uniquely fulfills a self punishment function
Slide104NESD Model
Temperament Self-injury Intense self-derogation Intense, negative emotions Normative/Low Environment self-derogation Other healthy & unhealthy coping
Slide105NESD Theory
Hypothesis: Those high in both negative
emotionality (NE) and self-derogation (SD) are
most likely to self-injure
Predicts a statistical interaction between NE and
SD in identifying self-injurers
Slide106Sample 1: Young Adults
2,011 Air Force recruits in basic training
Thomas, Turkheimer, & Oltmanns. (2003). Factorial structure of pathological personality traits as evaluated by
peers.
Journal of Abnormal Psychology
.
Mean age 20 (SD=5), 62% Male, 65% Caucasian,
17% African American
Administered the Schedule for Nonadaptive and Adaptive
Personality (SNAP; Clark, 1996)
Slide107Self-Injury
“When I get very tense, hurting myself physically somehow calms me down”
“I have hurt myself on purpose several times”
1% endorsed both of these items
Slide108Negative Emotionality
SNAP Negative Temperament Scale
28 items: “I often have strong feelings such as anxiety
or anger..”
True-False format
Slide109Self-Derogation
SNAP Self-Derogation/Low Self-Esteem scale
7 items: “I’ve really made a mess of my life”
True-False format
Slide110Results
Frequent Injurers Control
Negative Emotionality (NE) 1.29 -.01
Self-Derogation (SD) 1.49 -.01
NE and SD interact to distinguish frequent cutters from
controls (Binary Logistic Regression: Wald’s
X
2
(1)
=3.24,
p=
.07)
Slide111Slide112Sample 2: Adolescents
432 high-school students
Ages 13-17, 61% Female
53% Caucasian, 19% Hispanic, 15% Asian,
11% African American
Slide113Self-Injury
Section I of the Inventory of Statements About Self-injury
(ISAS; Klonsky & Olino, 2008; Klonsky & Glenn, in press)
Self-injurious behaviors done “intentionally” and “without
suicidal intent”
12 different behaviors: “cutting,” “scratching,” “needle-
sticking”
6.5% Cut 3 or more times
Slide114Negative Emotionality
Composite of two measures
Positive and Negative Affect Scale (PANAS; Watson & Clark, 1994)
10-items: “Upset,” “Ashamed,” “Irritable” [just NA scale]
Difficulties in Emotion Regulation Scale (DERS; Gratz, 2004)
36-items: “When I’m upset, my emotions feel overwhelming”
PANAS NA scale and DERS correlated
r
=.68
Slide115Self-Derogation
Composite of three measures
Self-Derogation scale from the Schedule for Nonadaptive and Adaptive Personality (SNAP; Clark, 1996)
7-items: “I’ve really made a mess of my life”
Self-Perception Profile for Adolescents-Revised (SPPA; Harter, 1988; Wichstrom, 1995)
Global Self-Worth 5-items: “often disappointed with [yourself]”
Physical Appearance 5-items: “not happy with the way [you] look”
Slide116Results
Frequent Cutters Control
Negative Emotionality (NE) 1.01 -.07
Self-Derogation (SD) 1.16 -.07
NE and SD interact to distinguish frequent cutters from
controls (Binary Logistic Regression: Wald’s
X
2
(1)
=3.86,
p
<.05)
Slide117Slide118NESD Theory: Next Steps
Preliminary evidence supports NESD theory
Examine large group of severe self-injurers
Consider functions of self-injury
(e.g., Klonsky & Olino, 2008)
Slide119How Does NSSI Work?
Parasympathetic Rebound Theory
Slide120Parasympathetic Rebound Theory
Sympathetic nervous system – “fight or flight”
Intense emotion: Fear, rage, panic
Increases heart rate
Increases blood flow to major muscle gruops
Parasympathetic nervous system – “rest and digest”
Limits effects of sympathetic system
Slows heart rate
Facilitates sustained engagement and attention
Slide121Parasympathetic Impairment
Inability to restrain sympathetic responses and emotions (panic, anger)
Impaired parasympathetic activity observed in self-injury and Borderline Personality Disorder
(Austin et al, 2007; Crowell et al., 2005; Weinberg, Hajcak, Klonsky, 2009)
Slide122Parasympathetic Rebound
Surges in sympathetic activity are followed by increases in parasympathetic activity
What if surges are too strong or too weak?
Too strong: fainting
Too weak: emotional dysregulation observed in BPD and self-injurers
Perhaps self-injury causes a surge in sympathetic activity which in turn triggers a strong parasympathetic rebound?
Slide123Parasympathetic Rebound
Some self-injurers report that seeing the blood is important for achieving calming influence of self-injury
(Glenn & Klonsky, 2010)
Interestingly, the fainting response observed in blood phobics is often attributed to parasympathetic rebound
The pain and blood caused by self-injury may
both
trigger a parasympathetic rebound
Slide124Parasympathetic Activity Pre- and Post- Self-Injury
NSSI
Mean
RSA
Minutes
Data from Matthew Nock, shown with permission (Nock & Mendes, in preparation)
Non-Suicidal Self-Injury:
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