1. Non-Suicidal Self-Injury: Description, Motivations, and Relationship to Suicide
E. David Klonsky, PhD
Associate Professor
Department of Psychology
University of British Columbia

2. Non-Suicidal Self-Injury
Common in youth and adolescents
Can be confused for attempted suicide
Has an important relationship to suicide risk

3. Agenda What is Self-Injury Who Self-Injures Why People Self-Injure
Relationship to Suicide

4. A Preliminary Note What we know (many many studies)
What we think (one or two studies)
What we don’t know (no research yet)

5. Agenda What is Self-Injury Who Self-Injures Why People Self-Injure
Relationship to Suicide

6. What is Self-Injury? Self-inflicted damage to body tissue Intentional
No suicidal intent
I think self-harm is a very interesting topic, is poorly understood and is often misunderstood. Important for practice, how to react to patients who self-harm. Important theoretically, why for some people does self-harm feel like a good thing to do?
I think self-harm is a fascinating topic, and one that is not well understood and often misunderstood. If you look to DSM-IV, self-harm appears once, as a criterion for borderline personality disorder. Yet in most treatment settings it’s apparent that self-harm can be found in patients with a variety of diagnoses (including those with major depression, eating disorders, bipolar disorders, schizophrenia, and substance disorders). I think this discrepancy is one indication that we don’t yet know what self-harm means when we see it in our patients. We know even less about self-harmers who do not find their way into clinics. How many people in non-clinical populations self-harm? Are they all pathological? Are there some self-harmers who function quite well day to day and don’t need treatment?
CASE STUDIES
How many people in non-clinical populations self-harm? What are they like? (Are they all pathological?)

7. 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.
Definition gets hazy quickly. 1) What does “deliberate” and “non-accidental” mean different things. Trichitillomania? Deliberate versus non-deliberate overdoses? Banging fist against wall (action deliberate, but harm not)? 2) What kind of damage? Damage to body tissue, vs bleeding, cutting, bruising. 3) without suicidal intent vs without apparent suicidal intent vs without consious suicidal intent

8. 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*
Definition gets hazy quickly. 1) What does “deliberate” and “non-accidental” mean different things. Trichitillomania? Deliberate versus non-deliberate overdoses? Banging fist against wall (action deliberate, but harm not)? 2) What kind of damage? Damage to body tissue, vs bleeding, cutting, bruising. 3) without suicidal intent vs without apparent suicidal intent vs without consious suicidal intent

9. Variation in Self-Injury
Frequency
Methods
Medical Severity
Contexts
Motivations
Desire/Efforts to Stop

10. Agenda What is Self-Injury Who Self-Injures Why People Self-Injure
Relationship to Suicide

11. Famous Self-Injurers
Princess Diana

12. Famous Self-Injurers
Angelina Jolie

13. Famous Self-Injurers
Christina Ricci

14. Famous Self-Injurers
Drew Barrymore

15. Famous Self-Injurers
Johnny Depp

16. Famous Self-Injurers
Eminem

17. Famous Self-Injurers
Marsha Linehan

18. Famous Self-Injurers Harry Potter’s Dobby
Klonsky, 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.
“Leaving out cites”

19. Who Self-Injures? Young Adolescents 8% High-School 14 - 15%
University Students 17%
General Adult Population 4-6%
Adolescent Inpatients %
Klonsky, E.D. & Muehlenkamp, J.J. (2007). Self-injury: A research review for the practitioner. Journal of Clinical Psychology: In Session.

20. Psychological Characteristics
Negative Emotions/Emotion Dysregulation
Depression
Anxiety
Anger
Self-Directed Negative Emotion
Suicide Ideation and Attempts

21. Defining Characteristic
Intense, Self-Directed Negative Emotions?

22. 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)

23. 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.

24. 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.

25. Agenda What is Self-Injury Who Self-Injures Why People Self-Injure
Relationship to Suicide

26. 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

27. 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.

28. 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].

29. 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.

30. 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.

31. 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.

32. 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.

33. Anti-Suicide 3rd 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.

34. Anti-Dissociation/Depersonalization
4rd 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.

35. Interpersonal Influence
5th 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.

36. Sensation/Excitement Seeking
6th 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.

37. 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.

38. 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.

39. Emotions and Self-Injury
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.

40. Emotions and Self-Injury
Before
Overwhelmed
Sad
Hurt Emotionally
During
Angry at Self
Hurt Emotionally
Isolated
After
Relieved
Angry at Self
Calm

41. Low-Arousal Negative Emotions

42. High-Arousal Negative Emotions

43. Low-Arousal Positive Emotions

44. Big Changes in Negative Arousal
Emotion Cohen’s d
Relieved
Calm
Overwhelmed
Anxious

45. 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

46. 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

47. 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

48. 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

49. Functions of Self-Injury
Organizing conceptual framework
Valid and comprehensive assessment

50. 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.

51. Sample I-SAS items “When I harm myself, I am…
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 distress
Marking 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.

52. 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

53. Intrapersonal Functions
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)
0.5 (1.3)
0.6 (1.4)
0.7 (1.3)
1.0 (1.4)
-.14
.21
. 35
.04
.64
.52
.54
.98
.53
.41
.87
.65
.69
.50
.42
.82
.84
.11
.26
.23
-.26
.16
.33
-.18
.02

54. Intrapersonal Functions
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)
0.5 (1.3)
0.6 (1.4)
0.7 (1.3)
1.0 (1.4)
-.14
.21
. 35
.04
.64
.52
.54
.98
.53
.41
.87
.65
.69
.50
.42
.82
.84
.11
.26
.23
-.26
.16
.33
-.18
.02

55. Relationship of Functions to NSSI Frequency
NSSI Behavior
Social Functions
α = .87
Intrapersonal Functions
α = .80
Cutting
Needle sticking
Carving
Banging/Hitting self
.19
.30
.18
.13
Note. All correlations are statistically significant at an alpha of .03.

56. Relationship of Functions to Cutting
Correlation with Cutting
Affect Regulation
Anti-Dissociation
Anti-Suicide
Marking Distress
Self-Punishment
Autonomy
Interpersonal Boundaries
Interpersonal Influence
Peer Bonding
Revenge
Self-Care
Sensation Seeking
Toughness
.21
.24
.23
.22
.04
.15
-.01
.09
.06
.11
Note. Correlations above .20 are statistically significant at an alpha of .001.

57. Relationship of Functions to Clinical Variables
Social Functions
α = .87
Intrapersonal Functions
α = .80
Depression
Anxiety
Borderline 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.

58. Relationship of Functions to Clinical and Contextual Variables
Clinical/Contextual Variable
Social Functions
α = .87
Intrapersonal Functions
α = .80
Suicidal Ideation
Suicide Plans
Attempted 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.

59. ISAS in Alexian Brothers Hospital
108 psychiatric patients
Ages 11 – 62, mean=19
90% female
72% Caucasian

60. Function Social Intrapersonal .77 .62 .50 .75 .67 .55 .44 .51 .95 .47
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

61. ISAS in an Adolescent Psychiatric Sample
80 psychiatric patients with NSSI from South Oaks Hospital in Long Island, NY
Mean age = 15 ( )
70% female
61% Caucasian

62. Function Social Intrapersonal .87 .83 .66 .63 .77 .79 .69 .54 .70 .36
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
Revenge
.70
Self-Care
.36
.37
Sensation Seeking
.73
Toughness
.72

63. 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)
Relive feeling numb/empty (I-N)
Punish self (I-P)
.58
Feel relaxed (I-P)
.54
First letter social or intrapersonal, second letter positive or negative

64. Two Motivational Dimensions
1. Self-Focused
2. Other-Focused

65. Two Motivational Dimensions
1. Self-Focused
2. Other-Focused
Affect Regulation
Anti-Dissociation
Anti-Suicide
Marking Distress
Self-Punishment

66. 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

67. Two Motivational Dimensions
1. Self-Focused
2. Other-Focused
More Self-Injury
More Psychopathology
More Suicidality

68. 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
Informs treatment

69. Agenda What is Self-Injury Who Self-Injures Why People Self-Injure
Relationship to Suicide

70. NSSI vs. Attempted Suicide
Differ in terms of intent and medical severity
Commonly co-occur
Avoid oversimplified conclusions!
Complex relationship needs careful study
Involuntary Hospitalization, Breaking Confidentiality and Trust, mobilizing emergency services when not necessary, perhaps missing someone truly suicidal because increased attention is paid to the salient wound resulting from non-suicidal self-injury

71. 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?
Involuntary Hospitalization, Breaking Confidentiality and Trust, mobilizing emergency services when not necessary, perhaps missing someone truly suicidal because increased attention is paid to the salient wound resulting from non-suicidal self-injury

72. Predictors of Attempted Suicide 139 Adolescent Psychiatric Inpatients
Suicide Ideation
NSSI
Borderline Personality Disorder .37
Depression
Anxiety
Impulsivity

73. Predictors of Attempted Suicide 426 High-School Students
Suicide Ideation
NSSI
Borderline Personality Disorder .29
Depression
Anxiety
Impulsivity

74. Predictors of Attempted Suicide 1,351 Undergraduates
Suicide Ideation
NSSI
Borderline Personality Disorder .22
Depression
Anxiety
Impulsivity

75. Predictors of Attempted Suicide 438 United States Adults
Suicide Ideation
NSSI

76. 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

77. ?? Why does NSSI have such a strong relationship to attempted suicide?
Thomas Joiner’s Interpersonal-Psychological Theory
Desire + Capability  Suicide

78. ?? Most risk factors only confer desire Others only confer capability
Depression
Hopelessness
Suicidal ideation
Others only confer capability
Access to lethal means
Combat exposure in military

79. ?? 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!

80. So what have we learned? Is NSSI a form of suicidal behavior? No!
Is NSSI unrelated to attempted suicide?
NSSI is different from attempted suicide, but
confers strong suicide risk because it represents
double-trouble (both desire + capability)

81. Suicide: Take-Home Message
NSSI is not attempted suicide, but…
… People who self-injure are at greater risk for suicidal ideation
… People who self-injure are more capable of acting on suicidal thoughts

82. For more information… Published 2011
User-friendly information for health professionals

83. Thank you Graduate Students Funding Sources 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

84. Questions, Comments, Discussion??
Thank you!!
Questions, Comments, Discussion??

85. Extra Slides

86. 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?

87. What BPD and NSSI Share Frequently co-occur
Both have emotion dysregulation as a core feature
Both associated with shame

88. 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?

89. Of those with BPD… … 78% NSSI … 84% Anxiety Disorder
… 84% Disruptive Behavior Disorder (ODD or Conduct)
… 78% Mood Disorder

90. Of those with NSSI… … 52% BPD … 74% Anxiety Disorder … 73% ADHD
… 66% Mood Disorder

91. 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

92. 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

93. Agenda What is Self-Injury Who Self-Injures Why People Self-Injure
Key Clinical Issues:
Borderline Personality Disorder
DSM-5
Suicide

94. A Distinct NSSI Diagnosis?
A symptom of a personality disorder in DSM-IV
Proposed as a Behavioral Disorder for DSM-V

95. The Process Group of Experts Lots of phone and email discussions
Members from Mood Disorders and Child/Adolescent Disorders Workgroups
Advisors with particular expertise in NSSI
Lots of phone and discussions
Separateness
Independent Clinical Significance
Threshold
Defining Characteristics
Differentiation from other Behaviors/Disorders

96. 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

97. 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.

98. Agenda What is Self-Injury Who Self-Injures Why People Self-Injure
Key Clinical Issues:
Borderline Personality Disorder
DSM-5
Suicide

99. 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

100. 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?

101. Many ways to cope with negative emotions …
why self-injury?

102. 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)

103. 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

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

105. 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

106. 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)

107. 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

108. Negative Emotionality
SNAP Negative Temperament Scale
28 items: “I often have strong feelings such as anxiety
or anger..”
True-False format

109. Self-Derogation SNAP Self-Derogation/Low Self-Esteem scale
7 items: “I’ve really made a mess of my life”
True-False format

110. Results Negative Emotionality (NE) 1.29 -.01
Frequent Injurers Control
Negative Emotionality (NE)
Self-Derogation (SD)
NE and SD interact to distinguish frequent cutters from
controls (Binary Logistic Regression: Wald’s X2(1)=3.24, p=.07)

112. Sample 2: Adolescents 432 high-school students Ages 13-17, 61% Female
53% Caucasian, 19% Hispanic, 15% Asian,
11% African American

113. 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

114. 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

115. 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”

116. Results Negative Emotionality (NE) 1.01 -.07
Frequent Cutters Control
Negative Emotionality (NE)
Self-Derogation (SD)
NE and SD interact to distinguish frequent cutters from
controls (Binary Logistic Regression: Wald’s X2(1)=3.86, p<.05)

118. 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)

119. Parasympathetic Rebound Theory
How Does NSSI Work?
Parasympathetic Rebound Theory
Informs treatment

120. 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
Informs treatment

121. 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)

122. 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?

123. 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

124. Parasympathetic Activity Pre- and Post- Self-Injury
Mean
RSA
Minutes
NSSI
Data from Matthew Nock, shown with permission (Nock & Mendes, in preparation)