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Non-Suicidal Self Injury (description, assessment and diagnosis)

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. Criteria for NSSI require:

• 5 or more days of intentional self-inflicted damage to the surface of the body without suicidal intent within the past year
• 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)
  • premeditation
  • ruminating on (non-suicidal) self-injury

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.

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 Adolescent NSSI in different clinical settings

Setting	Reference	Base Rate	Demography	Diagnostic Method
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)

Sources consulted: Nock (Eds.), Understanding nonsuicidal self-injury: Origins, assessment, and treatment. Washington, DC: Am. Psychol. Assoc.

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

Comparison of screening and outcomes measures

• Recommended Diagnostic Interviews:
  • The SITBI is the best clinical interview for assessing adolescent NSSI
  • The SASII was designed to assess NSSI among adults.

Suggested Clinical Interviews that Directly Assess NSSI:

Clinical interviews	Inter-rater reliability	Test-retest reliability	Interinformant agreement	Construct validity	Assesses Presence	Assesses Frequency	Assesses Method	Assesses Funciton	Assesses Severity
Self-Injurious Thoughts and Behaviors Interview (SITBI; Nock et al., 2008)	Lifetime (κ = 1.0) Current (κ = 1.0)	ICC = .71 (retest occurred 6 months later)	Lifetime (κ = 1.0)	Comparison with KSADS (κ = 0.74) Comparison with FASM current (κ = 1.0) Comparison with FASM lifetime (κ = 0.99)	✓	✓	✓	✓	✓
Suicide Attempt Self-Injury Interview (SASII; Linchan, Comtois, Brown, Heard, & Wagner, 2006)	ICC=.92 for general classification ICC=.84 for classification of single vs cluster of events			Comparison with medical eval (ICC=.85 medical lethality) Comparison with chart note frequency (ICC=.86) Comparison with diary card (ICC=.91)	✓	✓	✓	✓	✓

Sources consulted: Nock (Eds.), Understanding non-suicidal self-injury: Origins, assessment, and treatment. Washington, DC: Am. Psychol. Assoc.

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

• Recommended Self-report:
  • For baseline assessment it cannot be determined if the DSHI, FASM, or ISAS is superior.
  • The DSHI or ISAS are recommended for use as progress or outcome measures, because there is more psychometric information available on these measures.

Suggested Self-report Measures that Directly Assess NSSI:

Self-report measures	Test-retest reliability	Construct validity	Internal consistency	Assesses Presence	Assesses Frequency	Assesses Method	Assesses Funciton	Assesses Severity
Deliberate self-harm inventory (DSHI; Gratz, 2001)	.68 (retest occured 3 weeks later)	r=.43 average correlation with like measures	α = .82	✓	✓	✓	✓	✓
Functional Assessment of Self-Mutilation (FASM; Lloyd Richardson, 1997)			α = .86	✓	✓	✓	✓	✓
Inventory of Statements about Self-Injury (ISAS; Klonsky, Glenn, 2009)	Median spearman correlation=.68 (range .52 to .83 depending upon the type of NSSI)		α = .88 for interpersonal functions α = .80 for intrapersonal function	✓	✓	✓	✓	✓

Sources consulted: Nock (Eds.), Understanding non-suicidal self-injury: Origins, assessment, and treatment. Washington, DC: Am. Psychol. Assoc.

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

Treatments

There is currently no empirically supported treatment for NSSI. 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.

References

Glenn, C. R., & Klonsky, E. D. (2011). One-year test-retest reliability of the inventory of statements about self-injury (ISAS). Assessment, 18, 375-379. doi: 10.1177/1073191111411669

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.

Gray N. S., Hill, C., McGleish, A., Timmons, D., MacCulloch, M. J., & Snowden, R. J. (2003). Prediction of violence and self-harm in mentally disordered offenders: A prospective study of the efficacy of HCR-20, PCL-R, and psychiatric symptomatology. Journal of Consulting and Clinical Psychology, 71, 443-451. doi: 10.1037/0022-006X.71.3.443

Guertin, T., Lloyd-Richardson, E., Spirito, A., Donaldson, D., & Boergers, J. (2001). Self-mutilative behavior in adolescents who attempt suicide by overdose. Journal of the American Academy of Child and Adolescent Psychiatry, 40, 1062-1069.

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, 455-469. doi: 10.1177/0272431608316604

Klonsky, D. E., & 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, 31, 215-219.

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, 303-312. doi: 10.1037/1040-3590.18.3.303

Lloyd-Richardson, E. E., Perrine, N., Dierker, L., & Kelley, M. L. (2007). Characteristics and functions of non-suicidal self-injury in a community sample of adolescents. Psychological Medicine, 37, 1183-1192. doi: 10.1017/S003329170700027X

Nock, M. K., Holmberg, E. B., Photos, V. I., & Michel, B. D. (2007). Self-injurious thoughts and behaviors interview: Development, reliability, and validity in an adolescent sample. Psychological Assessment, 19, 309-317. doi: 10.1037/1040-3590.19.3.309.

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.