Non-Suicidal Self-Injury:

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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

Slide2

Non-Suicidal Self-Injury

Common in youth and adolescents

Can be confused for attempted suicide

Has an important relationship to suicide risk

Slide3

Agenda

What is Self-Injury

Who

Self-Injures

Why

People Self-Injure

Relationship to Suicide

Slide4

A Preliminary Note

What we know (many

many

studies)

What we think (one or two studies)

What we don’t know (no research yet)

Slide5

Agenda

What is Self-Injury

Who

Self-Injures

Why

People Self-Injure

Relationship to Suicide

Slide6

What is Self-Injury?

Self-inflicted damage to body tissue

Intentional

No suicidal intent

Slide7

What 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*

Slide9

Variation in Self-Injury

Frequency

Methods

Medical Severity

Contexts

Motivations

Desire/Efforts to Stop

Slide10

Agenda

What is Self-Injury

Who

Self-Injures

Why

People Self-Injure

Relationship to Suicide

Slide11

Famous Self-Injurers

Princess Diana

Slide12

Famous Self-Injurers

Angelina Jolie

Slide13

Famous Self-Injurers

Christina Ricci

Slide14

Famous Self-Injurers

Drew Barrymore

Slide15

Famous Self-Injurers

Johnny Depp

Slide16

Famous Self-Injurers

Eminem

Slide17

Famous Self-Injurers

Marsha Linehan

Slide18

Famous 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.

Slide19

Who 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

.

Slide20

Psychological Characteristics

Negative

Emotions/Emotion

Dysregulation

Depression

Anxiety

Anger

Self-Directed Negative Emotion

Suicide Ideation and Attempts

Slide21

Defining Characteristic

Intense, Self-Directed Negative Emotions

?

Slide22

What 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)

Slide23

Child 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.

Slide24

Child 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.

Slide25

Agenda

What is Self-Injury

Who

Self-Injures

Why

People Self-Injure

Relationship to Suicide

Slide26

Why 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

Slide27

Why 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.

Slide28

Why 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].

Slide29

Why 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.

Slide30

Why 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.

Slide31

Emotion 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.

Slide32

Self-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.

Slide33

Anti-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.

Slide34

Anti-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.

Slide35

Interpersonal 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.

Slide36

Sensation/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.

Slide37

Why 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.

Slide38

Why 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.

Slide39

Emotions 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

.

Slide40

Emotions and Self-Injury

BeforeOverwhelmedSadHurt Emotionally

DuringAngry at SelfHurt EmotionallyIsolated

After

Relieved

Angry at Self

Calm

Slide41

Low-Arousal Negative Emotions

Slide42

High-Arousal Negative Emotions

Slide43

Low-Arousal Positive Emotions

Slide44

Big Changes in Negative Arousal

Emotion

Cohen’s

d

Relieved +2.25

Calm +1.39

Overwhelmed - 0.89

Anxious - 0.81

Slide45

Why 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

Slide46

Why 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

Slide47

Why 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

Slide48

Why 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

Slide49

Functions of Self-Injury

Organizing conceptual framework

Valid and comprehensive assessment

Slide50

Inventory 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…

Slide52

Inventory 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

Slide53

ISAS 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

Slide54

ISAS 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

Slide55

Relationship 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.

Slide56

Relationship 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.

Slide57

Relationship 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.

Slide58

Relationship 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.

Slide59

ISAS in Alexian Brothers Hospital

108 psychiatric patients

Ages 11 – 62, mean=19

90% female

72% Caucasian

Slide60

Function

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

Slide61

ISAS 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

Slide62

Function

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

Slide63

FASM 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

Slide64

Two Motivational Dimensions

1. Self-Focused

2. Other-Focused

Slide65

Two Motivational Dimensions

1. Self-Focused

2. Other-Focused

Affect

Regulation

Anti-Dissociation

Anti-Suicide

Marking Distress

Self-Punishment

Slide66

Two 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

Slide67

Two Motivational Dimensions

1. Self-Focused

2. Other-Focused

More Self-Injury

More Psychopathology

More

Suicidality

Slide68

NSSI 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

Slide69

Agenda

What is Self-Injury

Who

Self-Injures

Why

People Self-Injure

Relationship to Suicide

Slide70

NSSI vs. Attempted Suicide

Differ in terms of intent and medical severity

Commonly co-occur

Avoid oversimplified conclusions!

Complex relationship needs careful study

Slide71

NSSI 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?

Slide72

Predictors of Attempted Suicide139 Adolescent Psychiatric Inpatients

Suicide Ideation .55

NSSI .50

Borderline Personality Disorder .

37

Depression

.20

Anxiety .16

Impulsivity .11

Slide73

Predictors of Attempted Suicide426 High-School Students

Suicide Ideation .51

NSSI .

38

Borderline Personality Disorder .29

Depression

.

24

Anxiety .18

Impulsivity

.11

Slide74

Predictors of Attempted Suicide1,351 Undergraduates

Suicide Ideation

.44

NSSI

.28

Borderline Personality Disorder .

22

Depression .24

Anxiety .16

Impulsivity

.10

Slide75

Predictors of Attempted Suicide438 United States Adults

Suicide Ideation .36

NSSI .34

Slide76

Summary 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

!

Slide80

So 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)

Slide81

Suicide: 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

Slide82

For more information…

Published 2011

User-friendly information for health professionals

Slide83

Thank 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

Slide84

Thank you!!

Questions, Comments,

Discussion??

Slide85

Extra Slides

Slide86

NSSI 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?

Slide87

What BPD and NSSI Share

Frequently co-occur

Both have emotion

dysregulation

as a core

feature

Both associated with shame

Slide88

Can 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?

Slide89

Of those with BPD…

… 78% NSSI

… 84% Anxiety Disorder

… 84% Disruptive Behavior Disorder (ODD or Conduct)

… 78% Mood Disorder

Slide90

Of those with NSSI…

… 52% BPD

… 74% Anxiety Disorder

… 73% ADHD

… 66% Mood Disorder

Slide91

NSSI 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

Slide92

Clinical 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

Slide93

Agenda

What is Self-Injury

Who

Self-Injures

Why

People Self-Injure

Key

Clinical Issues

:

Borderline Personality Disorder

DSM-5

Suicide

Slide94

94

A Distinct NSSI Diagnosis?

A symptom of a personality disorder in DSM-IV

Proposed as a Behavioral Disorder for DSM-V

Slide95

95

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

Slide96

And the proposed NSSI diagnosis is ………..

…not going to take effect in DSM-5

… but will appear in DSM-5 appendix as a research diagnosis

Slide97

A.  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

Slide98

Agenda

What is Self-Injury

Who

Self-Injures

Why

People Self-Injure

Key

Clinical Issues

:

Borderline Personality Disorder

DSM-5

Suicide

Slide99

Some 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

Slide100

Choose 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?

Slide101

Many ways to cope with negative emotions …

why self-injury?

Slide102

Self-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

)

Slide103

NESD 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

Slide104

NESD Model

Temperament Self-injury Intense self-derogation Intense, negative emotions Normative/Low Environment self-derogation Other healthy & unhealthy coping

Slide105

NESD 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

Slide106

Sample 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)

Slide107

Self-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

Slide108

Negative Emotionality

SNAP Negative Temperament Scale

28 items: “I often have strong feelings such as anxiety

or anger..”

True-False format

Slide109

Self-Derogation

SNAP Self-Derogation/Low Self-Esteem scale

7 items: “I’ve really made a mess of my life”

True-False format

Slide110

Results

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)

Slide111

Slide112

Sample 2: Adolescents

432 high-school students

Ages 13-17, 61% Female

53% Caucasian, 19% Hispanic, 15% Asian,

11% African American

Slide113

Self-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

Slide114

Negative 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

Slide115

Self-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”

Slide116

Results

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)

Slide117

Slide118

NESD 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)

Slide119

How Does NSSI Work?

Parasympathetic Rebound Theory

Slide120

Parasympathetic 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

Slide121

Parasympathetic 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)

Slide122

Parasympathetic 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?

Slide123

Parasympathetic 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

Slide124

Parasympathetic Activity Pre- and Post- Self-Injury

NSSI

Mean

RSA

Minutes

Data from Matthew Nock, shown with permission (Nock & Mendes, in preparation)


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