User:Ongmianli/Portfolios/Non suicidal self injury

Demographic Information

This section describes the demographic setting of the population(s) sampled, base rates of diagnosis, country/region sampled and the diagnostic method that was used. Using this information, clinicians will be able to anchor the rate of Non-Suicidal Self Injury that they are likely to see in their clinical practice.

Base Rates of NSSI in Different Populations and Clinical Settings

Setting	Reference	Base Rate	Demography	Diagnostic Method
Young adult non-clinical sample	Lifetime frequency; Swannell et al., 2014	13.4%	International	Meta-analysis, controlling for methodological differences across studies
Adult community sample	Lifetime frequency; Andover, 2015	23%	All of U.S.A.	Self-report measure (questions based on proposed DSM-V criteria for NSSI Disorder; FASM)
Adolescent inpatient sample	Lifetime frequency; Glenn & Klonsky, 2013	50%	North East	Self-report measure (ISAS), based on DSM-V criteria for NSSI Disorder
Adolescent community sample	Lifetime frequency; Zetterqvist et al., 2013	43.4%	Sweden	Combined self-report measure (FASM) and interview (SITBI)
Adult outpatient sample	Lifetime frequency; Selby et al., 2012	11.4%	U.S.A.	Chart review, not based on DSM-V criteria
Adolescent epidemiological	Lifetime frequency; Jacobson & Gould, 2007	13.0%-23.2%	All of U.S.A.	Variable assessment methods
Adolescent non-clinical sample	within the last year; Hilt et al., 2008	7.5%	North East	Self-report measure
Adolescent inpatient sample	lifetime frequency; Nock et al., 2006	60%	North East	Self-report measure (FASM)
Incarcerated sample	Gray et al., 2003	52%	United Kingdom	Self-report measure (FASM)

Search terms: [Non-suicidal self-injury or NSSI or Self harm] AND [children OR adolescents] AND [prevalence OR incidence OR epidemiological] in PsychInfo and Google Scholar

Diagnosis

DSM-V Criteria and Diagnostic Changes

Whereas in DSM-IV non-suicidal self-injury (NSSI) was considered a symptom of borderline personality disorder (BPD), in the revised manual it is recognized as a distinct condition. Research suggests that NSSI can occur independent of BPD, such as in patients with depression or even in those with no other diagnosable psychopathology. In the newest version of the manual (DSM-IV), non-suicidal self-injury (NSSI) is listed as a "condition for further study." The proposed preliminary criteria for NSSI are as follows:

• 5 or more days of intentional self-inflicted damage to the surface of the body likely to induce bleeding, bruising, or pain (e.g., cutting, burning, stabbing, hitting, excessive rubbing), with the expectation that the injury will lead to only minor or moderate physical harm (i.e., without suicidal intent) within the past year.

Note: The absence of suicidal intent has either been stated by the individual or can be inferred by the individual's repeated engagement in a behavior that the individual knows, or has learned, is not likely to result in death.

• Patients also must engage in the self-injurious behavior with at least 1 of the following expectations:
  • to seek relief from a negative feeling or cognitive state
  • to resolve an interpersonal difficulty
  • to induce a positive state
• The behavior must also be associated with 1 of the following criteria:
  • interpersonal difficulty or negative feelings and thoughts (eg, depression, anxiety)
  • preoccupation with the intended behavior that is difficult to control
  • ruminating on (non-suicidal) self-injury frequently, even when not acted upon
• The behavior must cause clinically significant distress or interference in interpersonal, academic, or other important areas of functioning.
• The behavior can not be better explained by another mental disorder or medical condition.

Socially sanctioned behaviors, like body piercing and tattooing, do not qualify for the diagnosis, nor do scab picking or nail biting. Important to note is that patients who express suicidal behavior within the past 24 months, but who don't qualify for another psychiatric disorder, now fall under the new "suicidal behavior" diagnosis category.

Comparison of Screening and Outcomes Measures

Instrument Types

• Omnibus Measures
  • Assess several NSSI domains
  • These tests are the most comprehensive compared to other measures
• Functional Measures
  • Helpful for understanding why people self-injure
  • These tests assess motives for, or functions of, NSSI
• Behavioral Measures
  • Primarily assess one's history of NSSI behaviors
  • These measures are useful for assessment methods used and NSSI frequency
• Brief Measures
  • Include a single item or a few items to assess NSSI
  • These may be best when conducting a brief assessment

Recommendations

• Omnibus measures are highly recommended over all other types of measures.
  • The SITBI is the best clinical interview for assessing adolescent NSSI
  • The SASII was designed to assess NSSI among adults.

Psychometric Properties of Instruments for Assessing Non-suicidal Self-Injury

Instrument	Internal Consistency	Interrater Reliability	Test-Retest Reliability	Construct Validity	Highly Recommended
Omnibus Measures
SASII	G	E	E	G	X
SITBI	NA	E	A	G	X
SBQ	G	NA	A	G	X
SHBQ	G	NA	A	G
Functional Measures
FASM	A	NA	U	A
ISAS	G	NA	G	G
SIQ	G	NA	U	A
SIMS	G	NA	U	A
SHRQ	G	NA	U	A
Behavioral Measures
DSHI	G	NA	G	G
SHI	A	NA	U	A
Brief Measures
SNAP Items	NA	NA	U	A
TSI Item	NA	NA	U	A

SASII, Suicide Attempt Self-Injury Interview (Linehan, et al., 2006); G, good; E, excellent; A, adequate; SITBI, Self-Injurious Thoughts and Behaviors Interview (Nock et al, 2007); NA, not applicable; U, unavailable; SBQ, Suicidal Behaviors Questionnaire (Linehan, 1981); SHBQ, Self-Harm Behavior Questionnaire (Gutierrez et al., 2001); FASM, Functional Assessment of Self-Mutilation (Lloyd-Richardson et al., 1997); ISAS, Inventory of Statements About Self-Harm (Glenn & Klonsky, 2007); SIQ, Self-Injury Questionnaire (Santa Mina et al., 2006); SIMS, Self-Injury Motivation Scale (Osuch et al., 1999); SHRQ, Self-Harm Reasons Questionnaire (Lewis & Santor, 2008); DSHI, Deliberate Self-Harm Inventory (Gratz, 2001); SHI, Self-Harm Inventory (Sansone et al., 1998); SNAP, Schedule for Nonadaptive and Adaptive Personality (Clark, 1996); TSI, Trauma Symptom Inventory (Briere, 1995)

Search terms: [Non-suicidal self-injury or NSSI or Self harm] AND [children OR adolescents] AND [assessment] in PsychINFO and Google Scholar

Sources consulted: Klonsky, E. D., & Lewis, S. P. (2014). Assessment of nonsuicidal self-injury. In M. K. Nock, M. K. Nock (Eds.) , The Oxford handbook of suicide and self-injury (pp. 337-351). New York, NY, US: Oxford University Press.; Nock (Eds.), Understanding non-suicidal self-injury: Origins, assessment, and treatment. Washington, DC: Am. Psychol. Assoc.

Scope of Instruments for Assessing Non-suicidal Self-Injury (NSSI)

Instrument	Type	No. Items	History	Methods	Frequency	Lethality	Intent of Functions	History of Suicidality
Omnibus Measures
SASII	I	31	X	X	X	X	X	X
SITBI	I	169	X	X	X	X	X	X
SBQ	S	90	X	X	X			X
SHBQ	S	32	X	X	X	X		X
Functional Measures
FASM	S	22	X	X	X	X	X
ISAS	S	39	X	X	X		X
SIQ	S	30	X	X	X	X	X	X
SIMS	S	35					X
SHRQ*	S	21	X	X	X		X
Behavioral Measures
DSHI	S	17	X	X	X	X
SHI	S	22	X	X	X	X
Brief Measures
SNAP Items	S	2	X					X
TSI Item	S	1	X		X

SASII, Suicide Attempt Self-Injury Interview; I, (structured) interview; S, self-report; SITBI, Self-Injurious Thoughts and Behaviors Interview; SBQ, Suicidal Behaviors Questionnaire; SHBQ, Self-Harm Behavior Questionnaire; FASM, Functional Assessment of Self-Mutilation; ISAS, Inventory of Statements About Self-Harm; SIQ, Self-Injury Questionnaire; SIMS, Self-Injury Motivation Scale; SHRQ, Self-Harm Reasons Questionnaire (* = revised SHRQ); DSHI, Deliberate Self-Harm Inventory; SHI, Self-Harm Inventory; SNAP, Schedule for Nonadaptive and Adaptive Personality, 375 items in the total measure; TSI, Trauma Symptom Inventory, 100 items in the total measure.

Search terms: [Non-suicidal self-injury or NSSI or Self harm] AND [children OR adolescents] AND [assessment] in PsychINFO and Google ScholarTreatment

Sources consulted: Klonsky, E. D., & Lewis, S. P. (2014). Assessment of nonsuicidal self-injury. In M. K. Nock, M. K. Nock (Eds.), The Oxford handbook of suicide and self-injury (pp. 337-351). New York, NY, US: Oxford University Press.; Nock (Eds.), Understanding non-suicidal self-injury: Origins, assessment, and treatment. Washington, DC: Am. Psychol. Assoc.

Treatment

According to Nock (2010), no treatment for NSSI could be considered "evidence-based." However, recent years have seen an increase in intervention trials for NSSI. Although limited due to lack of consistency in defining and measuring NSSI, this work could provide insight into potential best practices for treating this condition (Andover, 2015).

Dialectical Behavioral Therapies

Dialectical Behavior Therapy has been shown to be effective in treating individuals with Borderline Personality Disorder (BPD) who engage in NSSI; however it has not been shown to be better than treatment as usual in a sample of individuals without BPD. In the absence of a better option, a DBT approach to treatment is the most evidence based.

Cognitive/Behavioral Therapies

Few research studies have tested cognitive-behavioral therapy (CBT) as a treatment specifically for NSSI. However, some studies have evaluated the efficacy of CBT trials in treating self-injury with and without suicidal intent. Manual-assisted cognitive therapy (MACT) is a 6-session CBT intervention focusing on functions of deliberate self-harm, emotion regulation, problem-solving skills, and relapse prevention. MACT has demonstrated mixed results for decreasing NSSI frequency and severity among adults (Tyrer et al., 2003; Weinberg, Gunderson, Hennen, & Cutter, 2006). Although MACT may be a promising intervention (Muehlenkamp, 2006), it should be evaluated in future studies. In one adolescent treatment trial, the Adolescent Depression Antidepressant Psychotherapy Trial (ADAPT), a decrease in NSSI behaviors was found at post-treatment for both SSRI and SSRI+CBT groups (Goodyer et al., 2007), although no differences were found between groups. In sum, findings from efficacy trials of CBT on NSSI outcomes are mixed, and more trials examining CBT as a treatment specifically for NSSI are needed.

Pharmacology

Pharmacological interventions are especially scarce. However, one study found that fluoxetine was effective at reducing NSSI frequency in a sample of 22 adults with major depressive disorder and either BPD or schizotypal personality disorder (Markovitz et al, 1991). A second trial found that antidepressant medications alone (SSRIs and SNRIs) were as effective as medication plus CBT in reducing NSSI among adolescents with MDD (Brent et al., 2009; Goodyer et al., 2007). Ziprasidone, an atypical antipsychotic, was found to be more effective in reducing NSSI behaviors among adolescents compared to another neuroleptic medication (Libal et al., 2005). Clonidine has also been effective as an intervention for acute NSSI urges and feelings of tension among a sample of patients with BPD (Philipsen et al., 2004), although the long-term effects are unknown.

Prevention Programs

Jacobs, Walsh, McDade, and Pigeon (2009) developed the only known prevention program for NSSI, the Signs of Self-Injury program (SOSI). This school-based prevention program is designed to increase awareness about NSSI among adolescents through psychoeducation about warning signs and symptoms and improvement of help-seeking behaviors and attitudes. One test of effectiveness and acceptance found the program to be feasible and effective at changing attitudes toward NSSI and increasing help-seeking among students (Muehlenkamp et al., 2010).

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5. Washington, D.C: American Psychiatric Association.

Andover, M. S., Wren, A., Schatten, H. T., Morris, B. W., Shashoua, M. Y., & Holman, C. S. (2015). Non-suicidal self-injury. In T. P. Gullotta, R. W. Plant, M. A. Evans, T. P. Gullotta, R. W. Plant, M. A. Evans (Eds.) , Handbook of adolescent behavioral problems: Evidence-based approaches to prevention and treatment (2nd ed.) (pp. 631-648). New York, NY, US: Springer Science + Business Media.

Brent, D. A. (2009). The treatment of SSRI-resistant depression in adolescents (TORDIA): In search of the best next step. Depression And Anxiety, 26(10), 871-874.

Briere, J. (1995). Trauma symptom inventory (TSI) professional manual. Odessa, FL: Psychological Assessment Resources.

Clark, L. A. (1996). Schedule for adaptive and nonadaptive personality: Manual for administration, scoring, and interpretation. Minneapolis: University of Minnesota Press.

Glenn, C. R., & Klonsky, E. D. (2013). Reliability and validity of borderline personality disorder in hospitalized adolescents. Journal Of The Canadian Academy Of Child And Adolescent Psychiatry / Journal De L'académie Canadienne De Psychiatrie De L'enfant Et De L'adolescent, 22(3), 206-211.

Glenn, C. R., & Klonsky, E. D. (2013). Nonsuicidal self-injury disorder: An empirical investigation in adolescent psychiatric patients. Journal Of Clinical Child And Adolescent Psychology, 42(4), 496-507

Goodyer, I., Dubicka, B., Wilkinson, P., Kelvin, R., Roberts, C., Byford, S., & ... Harrington, R. (2007). Selective serotonin reuptake inhibitors (SSRIs) and routine specialist care with and without cognitive behaviour therapy in adolescents with major depression: Randomised controlled trial. BMJ: British Medical Journal, 335(7611), 142

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.

Gutierrez, P. M, Osman, A., Barrois, F. X., & Kopper, B. A. (2001). Development and initial validation of the self-harm behavior questionnaire. Journal of Personality Assessment, 77, 475–490.

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.

Jacobs, D., Walsh, B. W., McDade, M., & Pigeon, S. (2009).Signs of self-injury prevention manual. Wellesley Hills, MA: Screening for Mental Health.

Jacobson, C. M., & Gould, M. (2007). The epidemiology and phenomenology of non-suicidal self-injurious behavior among adolescents: A critical review of the literature. Archives Of Suicide Research, 11(2), 129-147.

Klonsky, E. D., & Lewis, S. P. (2014). Assessment of nonsuicidal self-injury. In M. K. Nock, M. K. Nock (Eds.), The Oxford handbook of suicide and self-injury (pp. 337-351). New York, NY, US: Oxford University Press.

Lewis, S. P., & Santor, D. A. (2008). Development and validation of the self-harm reasons questionnaire. Suicide and Lifethreatening Behavior, 38, 104–115.

Linehan, M. M. (1981). Suicide behaviors questionnaire. University of Washington, Seattle.

Linehan, M. M., Comtois, K. A., Brown, M. Z., Heard, H. L., & Wagner, A. (2006). Suicide attempt self-injury interview (SASII): Development, reliability, and validity of a scale to assess suicide attempts and intentional self-injury. Psychological Assessment, 18, 302–312.

Libal, G., Plener, P. L., Ludolph, A. G., & Fegert, J. M. (2005). Ziprasidone as a weight-neutral alternative in the treatment of self-injurious behavior in adolescent females. Child and Adolescent Psychopharmacology News, 10, 1–6.

Lloyd-Richardson, E. E., Kelley, M. L., & Hope, T. (1997, April). Self-mutilation in a community sample of adolescents: Descriptive characteristics and provisional prevalence rates. Poster session presented at the Annual Meeting of the Society for Behavioral Medicine, New Orleans, LA.

Markovitz, P. J., Calabrese, J. R., Schulz, S. C., & Meltzer, H. Y. (1991). Fluoxetine in the treatment of borderline and schizotypal personality disorders. American Journal of Psychiatry, 148, 1064–1067.

Muehlenkamp, J. J. (2006). Empirically supported treatments and general therapy guidelines for non-suicidal self-injury. Journal of Mental Health Counseling, 28, 166–185.

Muehlenkamp, J. J., Walsh, B. W., & McDade, M. (2010). Preventing non-suicidal self-injury in adolescents: The signs of self-injury program. Journal Of Youth And Adolescence, 39(3), 306-314.

Nock, M. K., Joiner, T. E., Gordon, K. H., Lloyd-Richardson, E., & Prinstein, M. J. (2006). Non- suicidal self-injury among adolescents: Diagnostic correlates and relation to suicide attempts. Psychiatry Research, 144 , 65–72.

Nock, M. K., Holmberg, E. B., Photos, V. I., & Michel, B. D. (2007). The self-injurious thoughts and behaviors interview: Development, reliability, and validity in an adolescent sample measure. Psychological Assessment, 19, 309–317.

Nock, M. K. (2010). Self-injury. Annual Review Of Clinical Psychology, 6339-363.

Osuch, E. A., Noll, J. G., & Putnam, F. W. (1999). The motivations for self-injury in psychiatric patients. Psychiatry, 62, 334–346.

Philipsen, A., Richter, H., Schmahl, C., Peters, J., Rüsch,N., Bohus, M., et al. (2004). Clonidine in acute aversive inner tension and self-injurious behavior in female patients with borderline personality disorder. Journal of Clinical Psychiatry, 65 , 1414.

Sansone, R. A., Wiederman, M. W., & Sansone, L. A. (1998). The Self-Harm Inventory: Development of a scale for identifying self- destructive behaviors and borderline personality disorder. Journal of Clinical Psychology, 54, 973–983.

Santa Mina, E. E., Gallop, R., Links, P., Heslegrave, R., Pringle, D., Wekerle, C., & Grewal, P. (2006). The self-injury questionnaire: Evaluation of the psychometric properties in a clinical population. Journal of Psychiatric and Mental Health Nursing, 13, 221–227.

Selby, E. A., Bender, T. W., Gordon, K. H., Nock, M. K., & Joiner, T. J. (2012). Non-suicidal self-injury (NSSI) disorder: A preliminary study. Personality Disorders: Theory, Research, And Treatment, 3(2), 167-175.

Swannell, 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 And Life-Threatening Behavior, 44(3), 273-303.

Tyrer, P., Thompson, S., Schmidt, U., Jones, V., Knapp, M., Davidson, K., et al. (2003). Randomized controlled trial of brief cognitive behavior therapy versus treatment as usual in recurrent deliberate self-harm: The POPMACT study. Psychological Medicine, 33, 969–976.

Weinberg, I., Gunderson, J. G., Hennen, J., & Cutter, C. J. (2006). Manual assisted cognitive treatment for deliberate self-harm in borderline personality disorder patients. Journal of Personality Disorders, 20, 482–492.

Zetterqvist, M., Lundh, L., & Svedin, C. G. (2013). A comparison of adolescents engaging in self-injurious behaviors with and without suicidal intent: Self-reported experiences of adverse life events and trauma symptoms. Journal Of Youth And Adolescence, 42(8), 1257-1272.