PowerPoint Presentation

Non-Suicidal Self-Injury as a Diagnosis Emily Brodie (07363522)Nicole Brucculeri (0784900)Alex Chisholm (0763274)

OverviewRecapNSSI Diagnostic CorrelatesNSSI DisorderCurrent ResearchClinical Utility of NSSI Future Directions/Summary

Brief Recap

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Terminology Clinical Utility: The usefulness of an intervention in a patients careBPD: Borderline Personality DisorderNSSI: Non-suicidal Self Injury

NSSINon-suicidal self-injury (NSSI) is the deliberate act of cutting, burning, scratching, hitting, bitting etc., to oneself in the absence of suicidal intent (Nock, 2010)

NSSI is engaged in for reasons not socially or culturally sanctioned 5

NSSIAdolescent populations: 13-45% engage in NSSI (Lloyd-Richardson et al., 2007)Clinical adolescent populations: SI rates range from 40-60%Adult populations: Around 4% engage in NSSI (Nock, 2010)Clinical adult populations: SI rates range from 19-25%Typical age of onset for SI is 14-24 years (Favazza & Conterio, 1989)

Onset can occur at any age6

NSSIFunctions of NSSI include (Nock, 2010):1.Affect Regulation2. Self-punishment3 Anti-Dissociation/ Anti-Suicide4. Sensation Seeking Most common from of SI is cutting or carving (Nock & Prinstein, 2004)

Many individuals use many forms of SI7

Diagnostic Correlates

Another significant concept to consider in regards to a NSSI diagnosis are the diagnostic correlates. Several studies have investigated such a relationship and found that many disorders relate to this diagnosis. 8

Non-suicidal self-injury among adolescents: Diagnostic correlates and relation to suicide attempts(Nock et al., 2006).NSSI

Axis I Disorders

Axis II Disorders

A study conducted by Nock et al., (2006), of 89 adolescent participants between the ages of 12 and 17 (23 males, 66 females) found that 87.6% of individuals with NSSI also met the criteria for an Axis I diagnosis.

51.7% of participants met the criteria for an internalizing disorder. 62.9% also met criteria for an externalizing disorder. 59.% of individuals also met the criteria for substance abuse disorder with the majority of this percentage going to nicotine dependence, however marijuana, and alcohol abuse and dependence were also found.

No gender differences were found except for those individuals suffering with major depressive disorder where women were more likely to have it, and conduct disorder where males were more likely to have it.

67.3% of participants furthermore, met criteria for a personality disorder in Axis II disorders. Most commonly associated with NSSI was borderline personality disorder, as well as avoidant and paranoid personality disorder.

70% of participants who recently engaged in NSSI reported to have had at least one suicide attempt. Females reported more suicide attempts than males. 9

An Exploratory Study of Correlates, Onset, and Offset of Non-Suicidal Self-Injury (Deliberto & Nock, 2008)

Family HistoryDevelopmental ComplicationsRepetitive Behaviour as ChildrenMethod of Birth

A study by Deliberto et al., 2008 has found that family history was related to NSSI diagnosis. Individuals with NSSI were more likely than non-injurers to have a family history of alcoholism, drug abuse, and suicidal ideation.

No differences were found in family history of anxiety, depression, bipolar disorder, or other psychiatric problems.

It was also found that 25% of individuals who engage in NSSI behaviour had in utero complications. Controls in contrast only experienced these complications in 6.7%.

29.4% of participants who engage in NSSI were also delivered by a caesarean section whereas 10% of controls were delivered through this method.

Birth weight, duration of pregnancy, duration of delivery, number of miscarriages experienced by the mother, delivery issues or problems followed by delivery were not correlated to NSSI.

History of repetitive behaviours during childhood were also correlated with NSSI. Individuals with NSSI who engaged in repetitive behaviours as a child were more likely to engage in NSSI behaviour almost 3 times more than those without NSSI.

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NSSI Disorder

HistoryNSSI has only been mentioned in the DSM for BPD (APA, 2000)NSSI Disorder was proposed as a criteria in 2009Child & Adolescent Workgroup for DSM-5 1. Prevalence2. Clinical and Functional Impairments3. Different From Other DiagnosesCriteria have been modified several times

NSSI has been mentioned in the DSM as a criteria for borderline personality disorderThis poses a problem because NSSI can occur outside of the context of BPDAssuming that NSSI is only a part of BPD may limit treatment optionsThus NSSI disorder would provide an opportunity to delineate NSSI from BPD and suicideChild and adolescent workgroup for the DSM 5 argued that NSSI disorder merited inclusionDifferent from other diagnoses1. Is distinct from suicidal behaviors, BPD, and psychiatric diagnoses

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PurposeCommunicationBetween clinicians and client TreatmentRepresent NSSI as a distinct populationFor those who engage in the behavior

What is the purpose of having an NSSI disorder or diagnosisCommunicationTreatment- Represent NSSI as a distinct population from BPD 13

Current Research on NSSI Disorder

Study 1: NSSI Disorder: A Preliminary Study (Joiner et al., 2012)Purpose: To compare the characteristics of NSSI with:The symptoms of borderline personality disorder (BPD)Axis I diagnosisTo determine whether NSSI should be considered a separate diagnosis

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MethodsConsisted of adult outpatients (N=571)Clinical assessment establishedMeasures: BDI-II, BAI, BSS, NSSI disorder criteria, MINI, SCID-I, SCID-II,GAF rating, and CGI

53% were female and from a university-based psychology clinicIndividuals accepted to take part in research upon admittance to this the clinicThere was a group of 65 individuals with NSSI and 24 individuals with borderline personality disorder. These individuals we compared to 482 individuals who did not have NSSI or borderline personality disorder

Patients were screened and then assigned to a separate therapist who learns the individuals psychological history, formulates their diagnosis, as well as their treatment plan- this is done in a 2-3 hour session a week. A clinical psychologist watches the process to ensure accuracy in diagnosis and treatment.

In order to ensure accuracy in therapists, they must pass a diagnostic exam where they diagnose individuals with Axis I or II disorders before being able to work in the clinic.

Patients asked how many times they have been to a mental health profession, have attended therapy, and have sought treatment for psychological issues. Beck Depression Inventory II- is a self-report with 21 items that assess depressive symptoms (a= .89)Beck Anxiety Inventory- is a self-report with 21 items to examine symptoms of anxiety a patient has experienced in the past 2 weeks (a = .90)Beck Scale for Suicide Ideation- is a self-report with 21 items that measure suicide ideation and intent within the last week (a=.94). Participants also asked about the number of times they have attempted suicide as well as the when was the last time they made an attempt. Participants were also asked questions about abuse, history of mood swings, history of recurrent conflict with others, experience of strange thoughts or beliefs, and aggression. NSSI disorder criteria- investigated participant reports of self-inflicted pain, injury or both in the last year; their self-injury did not meet criteria of BPD; self injury was not a result of mental retardation or autism spectrum disorder. Mini International Neuropsychiatric Interview and Structured Clinical Interview for the DSM-IV Axis I- determine whether participants had Axis I disorders. Structured Clinical Interview for DSM-IV Axis II personality disorders- to assess whether participants had a personality disorder. Global Assessment of Functioning- to determine patients ability to function as well as to establish the severity of their symptoms.Clinical Global Impressions- the therapist rated the patient after the first session on the basis of the severity of the patients illness.

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ResultsNSSI participants reported less than four symptoms of BPDNSSI participants reported higher levels of mood disorders, Cluster A personality disorder, suicide attempts, and anxiety levels than the comparison grouphigher CGI, lower GAF, worse psychopathology than comparison groupBPD reported higher levels of depression.

There were higher rates of BPD in females than in comparison group and NSSI group37% depressive-bipolar disorders21% were diagnosed with anxiety disorders9% substance disorders25% other disorders8% had less severe disorders (adjustment disorder, ADHD)

Within the sample, all participants but one had at least one Axis I disorderThose with NSSI had a higher rate of mood disorder as well as cluster A personality disorders. Those with BPD were higher only in depression. NSSI group has less than four symptoms of bipolar disorderNSSI participants had a higher CGI, a lower global assessment function, as well as more previous treatments than the comparison group. Participants with NSSI had a higher amount of suicide attempts, worse psychopathology, and anxiety levels than the comparison group. NSSI and BPD participants reported higher rates of abuse, mood swings, recurrent conflicts with others, strange thoughts and beliefs, as well as aggression.17

LimitationsThe data for this study was obtained through charts of treatment-seeking patients at a clinicStandardized clinical interview was not used to assess NSSIThose who were assessed for NSSI were only those who viewed this behaviour as problematicSmall number of participants for BPDThe group of participants with BPD included some who also had NSSI which may account for differences where BPD seems more impaired

The data for this study was obtained through charts of treatment-seeking patients at a clinicStandardized clinical interview was not used to assess NSSIThose who were assessed for NSSI were only those who viewed this behaviour as problematicSmall number of participants for BPDThe group of participants with BPD included some who also had NSSI which may account for differences where BPD seems more impaired

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Study 2: NSSI Disorder: Clinician and Expert Ratings (Lengel & Mullins-Sweatt, 2013) Purpose: to investigate whether the DSM-5 criteria truly reflect the symptoms experienced by individuals who engage in NSSI behaviour

Methods Clinicians randomly selected (N= 97) Self-reportMeasures: Demographic survey, and NSSI prototype survey

This study surveyed clinicians as well as NSSI researchers. Clinicians were randomly selected form the American Psychological Association division.They were identified through searching for articles with NSSI incorporated in it.

There were 53 male, and 44 female participants.Age ranged from 24-8983.2% were Caucasian, 3.4% were Hispanic, and 7.60% were other. 5.90% did not report their ethnicity.

Various different fields of psychology. Some included clinical psychology, counseling psychology, education, psychiatry, social work, and other. Theoretical backgrounds included cognitive, psychodynamic, behavioural, interpersonal systems, humanistic, neurobiological, and other.

Demographic survey- asked information on the individuals gender, age, ethnic background, marital status, degree completed, sub-field, theoretical orientation, and percentage of time they spend providing clinical services.

NSSI prototype survey- individuals were asked to describe a NSSI case in terms of the DSM-5 criteria.For Criterion A they were asked to whether 4 separate components represented NSSI. For Criterion B and C, ratings were given on symptoms the client experiences.

Experiment was done through mail.

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ResultsMost participants were found to be moderately familiar with the NSSI construct and vaguely familiar with the DSM-5 criteriaParticipants found the diagnostic criteria for NSSI in the DSM-5 to be accurate. All criteria had some support from participantsDisparity in the idea that NSSI behaviour causes clinically significant distress or impairment.

Negative affect prior to NSSI behaviour, a period of preoccupation with NSSI behaviour, and engaging in NSSI with a purpose and anticipated outcome had the highest agreement.

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LimitationsOnly 10% respondedResearchers may not keep up with current researchProfessionals were not asked to consider NSSI outside of BPD

Study 3: NSSI Disorder: An Empirical Investigation in Adolescent Psychiatric Patients (Glenn & Klonsky, 2013)Currently in the DSM-IV NSSI is classified as a criterion for BPD. However, there is a strong push to include it in the DSM-V as its own disorder. To do this 2 key assumptions must be addressed1. NSSI is unlikely to occur without a BPD diagnosis2. NSSI does not have clinical significance outside the context of BPD Purpose: to evaluate these specific assumptions

-a distinct NSSI disorder will now be included inDSM5as a condition requiring further study.-at this time, there is little direct evidence supporting theDSM5proposal over theDSMIVclassification.**over sampled for NSSI behaviour 23

MethodsN = 198Adolescents were recruited from a psychiatric inpatient program Used different measures to:Determine if participants met the proposed criteria for NSSI disorder, and the differences between those who did and did not.

(Referring back to the 2 key assumptions) Examined the possible co-occurrence of NSSI disorder and BPDExamined the association of clinical impairment and NSSI

Measures: ISAS, DSM-IV BPD criteria, Difficulties in Emotion Regulation scale, Loneliness Scale, MINI KID

-524 potential participants-ethnic composition of the sample was 64% Caucasian, 14% Hispanic, 10% African American, and 12% mixed or other ethnicity-74% female-ages 12-18

-ISAS: reliable and valid measure of NSSI frequency and functions, lifetime frequency of 12 different NSSI behaviors performed intentionally (i.e., on purpose) and without suicidal intent-DSM-IV BPD criteria: structured interview, asses the 9 BPD criteria, -Difficulties in Emotion Regulation scale: good validity for adolescents, 36 items that assess six different aspects of emotion regulation difficulties, Awareness, Clarity, Nonacceptanceof emotions etc. -Loneliness: 10-item measure, was used to assess loneliness and social isolation -MINI KID: Mini-International Neuropsychiatric Interview for Children and Adolescents, diagnostic structured interview, asses suicide ideation and attemps

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Results78% of the self-injuring sample met the criteria for NSSI disorder52% of the participants who met the criteria for NSSI disorder also met the criteria for multiple anxiety disorders (not just BPD). Meaning there is no critical link between NSSI and BPDThe NSSI disorder group had higher levels of suicide ideation, suicide attempts, loneliness and emotion dysregulation*The suggests an overall higher level of clinical impairment This research suggests that NSSI should be classified as an independent disorder, separate from BPD

Clinical impairment was operationalized as (a) past month suicide ideation and attempts, (b) emotion dysregulation, and (c) loneliness.

-overlap with BPD, results indicate that co-occurrence between NSSI disorder and BPD is moderate and similar to co-occurrence of BPD with mood and anxiety disorders.(anxiety, mood, bulimia)

regarding clinical significance, findings suggest that NSSI disorder is associated with clinical impairment over and above a diagnosis of BPD.25

Limitations/Future DirectionsThis research was completed before the DSM-V released the criteria for NSSI as an independent disorderSample was mainly Caucasian femalesMore research should be conducted using the DSM-Vs criteria for NSSI

NSSI Disorder CriteriaWhat criteria do you think the DSM 5 should include for NSSI?

NSSI Disorder Criteria (DSM-5) Andover (2014)

- These were the final proposed criteria for the DSM VIntentional self-inflicted injury- performed with the expectation of physical harm, but without suicidal intent, on five or more days in the past yearBehaviour is not socially sanctioned but is more significant than nail biting or picking at a scab Behaviour causes clinically significant distress or impairment The behaviour does not occur exclusively in the context of another disorder and cannot be accounted for by another mental or medical disorder 28

NSSI Disorder Criteria (DSM-5)

Andover (2014)

The behaviour is performed for at least 1 of the following reasons 1. To relieve negative thoughts or emotions 2. To resolve an interpersonal problem3. to cause a positive feeling or emotion

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NSSI Disorder Criteria (DSM-5) Andover (2014)

The behaviour is associated with at least one of the following:1. negative thoughts or feelings or interpersonal problems that occur immediately prior to engaging in NSSI2. Preoccupation with NSSI that is difficult to resist 30

Study 4: Clinical Utility of Proposed NSSI Diagnosis A Pilot Study (Benezeder, Odelius, & Ramklint, 2013)Purpose: To test the clinical utility of NSSI as a diagnosis as it is proposed for the fifth revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM) Looked at:NSSI criteria compared to suicidal behaviour NSSI criteria separate from BPD diagnosis

*hypothesized that patients fulfilling the criteria for NSSI would be difficult to separate from patients with suicidal behavior. *hypothesized that the NSSI diagnosis could be secluded from the BPD diagnosis31

Methods1. Anonymous questionnaires N = 201

Cross-Sectional Study: Participants were contacted through psychiatric outpatient facilities Carried out in 2 steps 2. Participants who reported self-harm behaviour were invited to be interviewed N = 39 -These participants fell into one of two groupsNSSI (n = 18)non-NSSI (n= 21)Measures: DSHI-9, Diagnostic criteria of NSSI, MINI, MINI-KID, SCID-II, Suicidality

-Done in Sweden -13-25 years old-34 women 5 men -3 out patient facilities

Group difference reason for not fulfilling the NSSI diagnosis was that the individual had either harmed themselves on too few occasions in the last year and/or that they did not suffer from a clinically significant distress or impairment due to their self-harm behavior-they did not fit into the proposed criteria for NSSI

DSHI-9: Shortened version of Gartzs original self harm assessment, this one only has 9 itemsasked in the past 6 months, had engaged in any of nine different self-harm behaviors, and to rate how many times they have engaged in each behavior on a scale from 0 (never) to 6 (more than five times)-Diagnostic criteria: DSM-V website, used in the questionnaire-MINI: mini international neuropsychiatric interview, assess 15 different disorders-MINI KID: used for people under 18, 24 disorders though -SCID-II: used to assess criteria for BPD -Suicidality: attempts, plans and ideations in the last month 32

ResultsNSSI diagnosis was found to be different from a BPD diagnosis NSSI group had a higher suicide riskWhen individuals self-harm more frequently they have a higher suicide riskStrong level of overlap between NSSI and suicidal behaviour

the first study to evaluate the proposed NSSI diagnostic criteria in a clinical population. Among these self-harming patients, 46% were assessed to fulfill the NSSI diagnosis.In previous studies, a link between non-suicidal self-injury and suicide attempts has been established The frequency of suicide attempts, as well as the lethality of the attempts, has been shown to correlate with the frequency of self-injury33

Limitations/Future Directions Pilot study, very small sample size Mostly females (34 females 5 males)More research using the DSM 5s criteria for NSSI Disorder should be conducted The proposed criteria should be revaluated to better separate suicide behaviours from NSSI

-people that didnt fall into the category typically didnt self harm very often (less than 5 times in the last year) and the behaviour didnt impair them *why?Discussion question maybe?34

Study 5: NSSI Disorder in a Community Sample of Adults (Andover, 2014)

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Methods

Mturk is an online market place where jobs are posted and workers select and complete jobs for pay, it has been used in several psychological studies and provides benefits such as an increased diversity in samples and faster data collection (equal or higher psychometric properties)Participants must be at least 18 years old and have a 95% completion rate for data to be used in the study; Could read description of study and then consent to participate in the online survey, a debriefing followed once the online survey was complete

Participant qualitiesMean age = 35.70 years SD 12.2346.5% of the sample was female79.7% of the sample reported their race as white with 6.8% as latino/a17.7% reported being in college

Completion of online surveyNSSI disorder- participates were asked if they intentional hurt themselves without the intent to die those who responded yes were asked to respond to questions as Criteria A, B, C, and E (from previously mentioned criteriaFor criteria A: Participants were asked to indicate the number of days in the past year which they engaged in NSSI For criteria B & C: participants were asked to respond yes, no, or I dont know to question for reasons of engaging in NSSI For criteria E: Participants responded yes, no, or I dont know to 2 different questions1. Assessing whether NSSI interfered with participants functioning2. Assessing if participant wanted to stop engaging in NSSI Internal consistence was a = 0,56Functional Assessment of Self-MutilationSelf report to measure specific characteristics of NSSI such as methods, frequency, age of onset, assesses four functions of NSSI (a = 0.92)Coping Strategy Indicator33 item self report to assess the degree to which participants used three coping strategies (problem soling, social support seeking, and avoidance) (a = 0.82)McLean Screening Instrument for Borderline Personality DisorderTen true or false statements that reflect nine criteria for BPD (self-injury question was not included) (a =0.83)A final sample yielded 125 participants

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Results

Almost of participants (23%) reported engaging in NSSI at least once in their lifetime, where 30% stated that they had no engaged in NSSI in the past year The average number of days that participants engaged in NSSI was 15 (SD 60!!) and ranged from 0- 265 days Criterion A we can see that 20% reported engaged in NSSI on five or more days to fulfill criteria A Criterion B 2/3rds of the sample fulfilled criteria B endorsing one of the reasons for engaging in NSSI (10% responded with I dont know) 37

Results

Over 80% of the sample endorsed at least one of three associated features of NSSI and when it was engaged in Frequent urges in NSSI was supported by 2.4% of participants a smaller percentage answered I dont know to this question

Overall 20% of individuals with a history of NSSI fulfilled criteria A,B and C (17.6%) of the sample 38

Results

Does NSSI interfere with functioning?Do you want to stop engaging in NSSI?These two questions were asked to endorse distress or impairment in functioning 24% of individuals answered I dont know to both questions Nearly 65% of individual's who have a history of engaged in NSSI reported clinically significant distress or impairment (N=81) Criterion D (not socially sanctioned was endorsed by 2.6% of the sample and criterion F (not better acocunt for by another disorder) was acocunted for by 11.2% of the sample for those with a history of NSSI39

Results: Clinical VariablesGroups did not differ in gender, ethnicity, or percentage enrolled in collegeThere was a significant effect of age Those with a history of NSSI regardless of diagnosis were more likely to be Caucasian Those without NSSI history endorsed fewer criteria for BPDUsed more problem solving strategies No difference in social support seeking strategies

Next researchers looked at clinical variables that differed in individuals with no history of NSSI (N=400) and those with a history of NSSI who did not meet criteria for the disorder (n= 111) and those with a history of NSSI who did meet criteria for the disorder (n= 14) Post hoc did not reveal anything further about age Used more problem solving startegies than idnivudals with NSSI disorder Suggests that those with NSSI report more symptoms of BPD and use poorer coping strategies

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Results: Clinical VariablesThose with NSSI disorder engage in NSSI on more days in the past yearWere more likely to report that behavior interfered with functioning Reported engaging in the behavior for more autonomic functions Groups did not differ in age of onset, lifetime NSSI frequency or NSSI methodsBoth groups reported wanting to stop engaging in NSSI

Researcher then investigated with those with NSSI disorder differed form those with NSSI history but not NSSI disorder Should be noted that those with NSSI disorder were more likely to engage in biting behavior Autonomic functions negative and positiveWanting to stop supports that those with or without the disorder may be equal in their likelihood to seek treatment

Overall, 23% of participants had a lifetime history of NSSI Nearly 3% of the total sample met criteria for A,B,C and E of NSSI Disorder for those with a history 11.2% met criteria 41

Limitations & Future DirectionsCriterion A clinical significanceCriterion for severe self-injurers not addressedCriterion E: Do you want to stop engaging in NSSI may not reflect impairment or distress Criterion D and F were not assessed Small sample sizeSelf-report data

Over 40% of those with a history reported engaging in NSSI more than 5 days but these did not differ significantly from those reporing the heaivoir on fewer than five days in endorsement of criterion B,C E Severe additional criteria may be necessary to identify indivudal with severe SI I dont know means indivudals may not understand the wuestion or may not know the answer or know themselves to give the right answer Self report is not likley to be used in clinican assessments but a semi-structured interview would be

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Future DirectionsRemoval or reevaluation of criteria not highly endorsedClarify and reword diagnostic criteria to make it understandablei.e. several individuals responded with I dont know Investigate differences for those with and without NSSI disorder on various psychopathologies i.e. suicidal thoughts, levels of depression NSSI disorder not otherwise specified

I dont know means individuals may not understand the question or may not know the answer or know themselves to give the right answer NSSI disorder NOS can be used for individuals who do not fit all criteria

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NSSI Disorder Controversy

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NSSI Disorder Controversy

Why do you think there is so much controversy surrounding NSSI Disorder?

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NSSI Disorder ControversyNSSI has a high degree of comorbidity with other psychiatric disorders!NSSI is not a marker for any one particular disorder (Whitlock et al., 2008)NSSI can be found among individuals with one or more psychiatric disordersCreates confusion about the true uniqueness of NSSI as a distinct disorderIt is not know if NSSI precedes onset of psychiatric disorders or results from an inability to cope with symptoms of a disorder(Levesque, 2012)

Clinical Utility of NSSI DiagnosisOverview of Research

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Clinical Implications and Future Directions

To have a diagnosis that individuals who self-harm feel like they can fit into.When published, the impact of an actual diagnosis on family members can be studied In the DSM-IV NSSI only shows up as a criterion for BPD. This can lead to improper care and misdiagnosis.With the addition of NSSI as an independent disorder in the DSM-V it allows for more research to be done. Specifically, this research will be more generalizable as studies will be able to use the same criteria.Having NSSI classified as an independent disorder will also increase the amount of treatment based research, thereby resulting in empirically validated treatments for NSSI

**reliability 48

Clinical UtilityIndividuals who engage in self-harm are at risk of inflicting more harm than intended to leading to life threatening injuriesTeach individuals that those who self-harm are not manipulative, attention seeking, untrustworthy, and/or uncooperativeRisk of becoming addicted to behaviour, habit forming behaviour, or not being able to control urgesTo help improve communication regarding self-injury and bring awarenessAt risk of suicide, and health issues such as infections and scarringTeach individuals how to effectively copeHelp individuals feel more in control of their lives

Why diagnose and treat NSSI?

Individuals who engage in self-harm are t risk of inflicting more harm than intended to, leading to life threatening injuries. Teach individuals that those who self-harm are not manipulative, attention seeking, untrustworthy, and/or uncooperativeRisk of becoming addicted to behaviour, habit forming behaviour, or not being able to control urgesTo help improve communication regarding self-injury and bring awarenessIndividuals who self-harm are at risk for suicide as well as health issues such as infections and scarringSelf-injury may habituate individual to fear and pain- NSSI sometimes deals with an individuals inability to cope- by learning diagnosing and treating NSSI you allow individuals learn how to effectively cope with negative events that occur in their lives appropriately and in manner that does not risk harming themselves. - Help individuals feel more control in their lives- Help individuals become happier individuals who are more resilient to negative experiences- makes them stronger - Addresses the potential causes and can create preventative measures that can protect individuals from engaging in this behaviour in the future. - Try to understand the reason why people engage in such behaviour- Could lead to further disorders that are damaging to the self- depression, anxiety etc- To help individuals understand that they are not alone, and are not abnormal in anyways. Their behaviour does not make them any less human or anymore crazy or weird. - Allows individuals to feel supported and attempt to be understood- they have nothing to feel guilty about - Can be damaging to the individuals sense of self- everyone has the right to feel significant- Can potentially give a sense of belonging they are not alone- Can help with teaching the individual how to communicate effectively - Shows that the individual does have a network of support

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Where Are We Now?NSSI Disorder was added to the DSM-5Accepted in Section 3Disorders Requiring Further ResearchAmerican Psychiatric Association, 2013

This means that more grants and funding for research will be available to researchers!50

SummaryNSSI Disorder criteria have been developedNSSI Disorder has been added to the DSM-5Further research is required for the utility of NSSI Disorder

Discussion Questions 1. How do you think people suffering from NSSI will react to its inclusion in the new addition of the DSM? Do you feel like the proposed criteria adequately define NSSI? Are they what you thought would be included?

2. As a parent how would you feel if your child was diagnosed with this disorder? Will parents be more reluctant to get their children help with this diagnosis?

3. Can this be another way for misdiagnosis due to the early stages of the disorder and due to the high level of comorbidity?

4 . How will different cultures react to this diagnosis? For instance, will some cultures be more reluctant to accept this as a disorder? (ie, individualistic vs. collectivistic cultures)

Time to take questions from class. If needed more discussion questions:-How do you think people suffering from NSSI will react to its inclusion in the new addition of the DSM?-How will different cultures react to this diagnosis? What cultural differences do you think may exist in NSSI (what cultures would be more likely to have the disorder?)Why study the cultural differences of NSSI? What can this knowledge contribute to? -As a parent how would you feel if your child was diagnosed with this disorder?-Do you feel like the proposed criteria adequetly define NSSI? Are they what you thought would be included?-Will parents be more reluctant to get their children help with this diagnosis? -Can this be another way for misdiagnosis due to the early stages of the disorder and due to the high level of cormorbidity?

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References Joiner Jr., T., Selby, E., Bender, T., Gordon, K., & Nock, M. (2012). Non-suicidal self-injury (NSSI) disorder: A preliminary study.Personality Disorders: Theory, Research, and Treatment,3(2), 167-175. doi: http://dx.doi.org.subzero.lib.uoguelph.ca/10.1037/a0024405Kuentzel, J., Arble, E., Boutros, N., Chugani, D., & Barnett, D. (2012). Nonsuicidal self-injury in an ethnically diverse college sample.American Journal of Orthopsychiatry,82(3), 291-7. doi: 10.1111/j 1939-0025.2012.01167.xLengel, G., & Mullins-Sweatt, S. (2013). Nonsuicidal self-injury disorder: Clinician and expert ratings.Psychiatry Research,210(3), 940-944. doi: http://dx.doi.org.subzero.lib.uoguelph.ca/10.1016/j.psychres.2013.08.047Levesque, R. J. (2012). Encyclopedia of adolescence (Vol. 1). Springer.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. http://dx.doi.org/10.1017/S003329170700027XManca, M., Presaghi, F., Cerutti, R. (2014). Clinical specificity of acute versus chronic self-injury: Measurement and evaluation of repetitive non-suicidal self-injury. Psychiatry Research, 215(1), 111-119

References Nock, M. K. (2010). Self-injury. Annual Review of Clinical Psychology, 6, 339-357. http://dx.doi.org/10.1146/annurev.clinpsy.121208.131258Nock, M. K., & Prinstein, M. J. (2004). A functional approach to the assessment of self-mutilative behavior. Journal of consulting and clinical psychology, 72(5), 885.Nock, M., Joiner Jr., T., Gordon, K., Lloyd-Richardson, E., & Prinstein, M. (2006). Non-suicidal self-injury among adolescents: Diagnostic correlates and relation to suicide attempts.Psychiatry Research,144(1), 65-72. doi: http://dx.doi.org.subzero.lib.uoguelph.ca/10.1016/j.psychres.2006.05.010Whitlock, J., Muehlenkamp, J., & Eckenrode, J. (2008). Variation in nonsuicidal self-injury: identification and features of latent classes in a college population of emerging adults. Journal of Clinical Child & Adolescent Psychology, 37(4), 725-735.Zetterqvist, M., Lundh, L. G., Dahlstrm, ., & Svedin, C. G. (2013). Prevalence and function of non-suicidal self-injury (NSSI) in a community sample of adolescents, using suggested DSM-5 criteria for a potential NSSI disorder. Journal of abnormal child psychology, 41(5), 759-773.

Extra Slides Removed due to time cap**

Overall Study LimitationsMost studies have not use finalized criteria Criteria have been determined based on self-report Not consistent with how clinicians diagnose individuals Not using a NSSI assessment toolAssessed only some aspects of criteria

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Study 2: Prevalence & Function of NSSI in a Community Sample of Adolescents, Using Suggested DSM-5 Criteria for a Potential NSSI Disorder (Zetterqvist et al., 2013)Purpose: to investigate thePrevalence ratesFunctionsCharacteristics of NSSI

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MethodsAdolescents (N = 3, 097)Completion of self-reportsFASM, SITBI,

Participants included 3, 097 adolescents who were between the ages of 15 and 17. Random SampleFrom vocational and theoretical education programs in order to give diversity in SES, ethnicity and gender. 70% were in their first year of high school 36 schools out of 48 schools stergtland were used49.5% boys and 50.5% girls8.5% were born outside of Sweden 61.1% lived with their parents46.6% in vocational programs 53.4% in theoretical programs

Data collection was performed in classrooms. Students were allowed to miss this class if they did not wish to participate and parents were notified. Students were debriefed in order to avoid any distress experienced while filling out the questionnaires.

The functional Assessment of Self-Mutilation- 22 statements assessing the functions of NSSI. Participants respond on a four-point Likert scale.

The Self-Injurious Thoughts and Behaviours Interview-Short Form-Self-Report- used a self-report version to assess presence, frequency, and characteristics of suicidal ideation, suicide plans, suicide gestures, suicide attempts, and NSSI.

Demographic questionnaire was given to students to further note their health-related behaviours.59

Results17.2% of participants report engaging in NSSI behaviourLifetime prevalence of NSSI was 41..6% of adolescentsMost common form of self harm was biting oneself followed by hitting yourself on purpose6.7% of individuals fulfilled the DSM-5 diagnosis Most reported function was to stop bad feelings

17.2% of participants report engaging in NSSI behaviour35.6% of participants reported at least one instance of self-injury in the past year12.2% reported only one instance of NSSI30.8% 2-5 incidents13.8% reported 6-10 incidents 41.2% reported 11 or more incidents. Lifetime prevalence of NSSI was 41.6% of adolescents. Mean debut incidence was 13.9 years old. Most common form of harm was through biting oneself 56% Hitting yourself on purpose was 43.7%erased your skin 32.6%Cut or carved on their skin 32.6%Giving yourself a tattoo 9.1%*** - this in our lecture notes states is not a method of NSSIPulling hair out 16.6%

6.7% of individuals fulfilled the DSM-5 diagnosis 8.7% adolescents reported five or more NSSI incidents without filling criteria B and C99.5% reported having engaged in NSSI with the expectation of the behaviour relieving interpersonal difficulty, negative feeling or cognitive state or induce a positive feeling98.5% had negative thoughts prior to engaging in the behaviour73.7% of participants engaged in NSSI less than 11 times in the last year23.2% did not acknowledge distress7.8% did not acknowledge impairment27.4% in the DSM-5 group confirmed having taken drugs or alcohol while engaging in NSSI behaviour in the last year. 77% females and 23% males engaged in the behaviour More females engaged in more than five incidents and engaged in the behaviour more in the last year than malesMost reported factors for NSSI behaviour was positive and negative automatic reinforcement. Majority of functions more reported by girls than boys. Functions reported were- to stop bad feelings- 46.9%o relieve feeling numb or empty- 45.6%To punish yourself- 40.7%To feel something- 38%

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LimitationsCross-sectional design does not consider causal relationshipsIndividuals may not remember the memory as accurateRisk that individuals who did not attend the self-report may be troubled leading to a systematic bias in drop-outMeasures used were not validated against other sources of information such as a clinical assessment

Cross-sectional design does not consider causal relationshipsIndividuals may not remember the memory as accurateRisk that individuals who did not attend the self-report may be troubled leading to a systematic bias in drop-outMeasures used were not validated against other sources of information such as a clinical assessment

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MethodsTwo Independent Samples N1 = 634 Undergraduate and high school studentsN2 = 953 High school students

Both groups completed a questionnaire The Repetitive Non-Suicidal Self-Injury Questionnaire (R-NSSI-Q) The questionnaire also included other measures: DSHI, BIS, LSC-r, How I deal with stress, SBQ-R

-In rome

Questionnaire 138 items rated on a 5-point Likert-like scale (1=Does not describe me at all to 5=Describes me completely).

-DSHI: deliberate self harm inventory, assesses various aspects of DSH, including the frequency, duration and type of DSH behaviors-BIS: body investment scale, elf-report measure of emotional investment in the body which investigates distorted bodily perceptions in relation to tendencies toward preserving/destroying life-LSC-r: life stressor checklist revised, 23 items, presence of particularly stressful or traumatic events in the participant's life.-How I deal with stress: 24 items asking for the use of a list of strategies that adolescents may employ to cope with stressful events-SBQ-R: Suicide Behaviors Questionnaire, 4-item questionnaire that measures past suicidal thoughts and attempts which have proved to be significant predictors of future suicidal feelings62

ResultsTwo levels of NSSI risk appeared: O-NSSILower risk individuals

R-NSSIHigher risk individuals No gender differences between groupsBoth groups have an age of onset of approximately 13.5

(R-NSSI) having a history of at least five or more self-injurious episodes and a minimum score of at least 21 on the R-NSSI-Q

-no gender differences, goes against the idea that it is predominantly female behaviour63

Limitations/Future DirectionsThis is a community study whereas the measures used (R-NSSI-Q) are typically used in clinical samples

The study is cross-sectional, and thereby only correlational

Future research should explore these levels in a longitudinal study to see if they are consistent or if they fluctuate

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Study 7: Clinical Specificity of Acute Versus Chronic Self-Injury (Manca, Presaghi, & Cerutti, 2014)Purpose: To differentiate the severity levels of NSSI using the proposed criteria for the DSM-V

Study 2: Proposed Diagnostic Criteria for the DSM-5 of NSSI in Female Adolescents: Diagnostic & Clinical Correlates (In-Albon, Ruf, Schmid, 2013)Purpose was to investigate the diagnostic criteria, the diagnostic and clinical correlates for validity

Methods Female Adolescents (N = 110)Self-reportsKinder-DIPS, DSM-5 criteria for NSSI, GAF, QTF, BSL, DERS, FASM, YSR, BDI-II

110 female adolescents who were inpatients at psychiatric units in Switzerland and Germany 41 adolescents who have NSSI according to the DSM-5 criteria12 Adolescents with NSSI but were denied as being impaired or distressed20 adolescents with a diagnosis that is not NSSI.

The Diagnostic Interview for Mental Disorders in Children and Adolescents: assess most frequent mental disorders in childhood and adolescence.

DSM criteria for NSSI

Global Assessment of Functioning: assesses overall patient functioning and symptom severity

The Questionnaire of Thoughts and Feelings: measures borderline-specific basic assumptions and negative feelings (a= .97)

The Borderline Symptom List assesses borderline-typical symptomatology (a= 0.84 to 0.96)

The Difficulties in Emotion Regulation Scale assesses aspects of emotion dysregulation (a= 0.80 to 0.93)

The Functional Assessment of Self-Mutilation measures methods, frequency, and functions of NSSI (a=0.85)

The Youth Self-Report measures psychopathology (a=0.90)

The Beck Depression Inventory-II: assesses depressive symptoms (a=0.96)

The Depression Anxiety Stress Scale- measures depression, anxiety, and stress (a= 0.93 for depression, a= 0.85 for anxiety, a= 0.84 for stress, and a= 0.94 for the total scale)67

ResultsNSSI was found to be comorbid with other psychopathological disorders in all but two subjects. Major depression was the most frequent. Adolescents with NSSI had more diagnoses of PTSD and suicide attempts compared with the other groups20.5% fulfilled the criteria for BPDIndividuals with NSSI have a higher level of impairment than adolescents with other mental disorders

85% of participants reported psychological precipitant, frequent urges, and contingent responsesLess than 50% participants reported preoccupation with the behaviour and difficulty resisting the urge.69% reported impairment at leisure time and distress

NSSI was found to be comorbid with other psychopathological disorders in all but two subjects. Major depression was the most frequent

Adolescents with NSSI had more diagnoses of PTSD and suicide attempts compared with the other groups20.5% fulfilled the criteria for BPD

Frequent symptoms wereAffective instability Intense anger

Least frequent symptomsIdentity disturbancesParanoid ideation/dissociative symptoms

NSSI report higher levels of depressionThey also experience higher psychopathology

Individuals with NSSI have a higher level of impairment than adolescents with other mental disorders68

LimitationsSample cannot be generalized as sample used was from a psychiatric unitSub-sample size was small causing power to be limited for some analysesDSM-5 was not yet completed

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NSSI and Culture

A question that should have significant attention is the aspect of NSSI and culture.

There are many questions to ask in regards to culture and NSSI. What culture has a higher prevalence rate of NSSI and what cultural differences may be causing it?How should cultural differences be investigated? Should we seek individuals within North America who have different ethnic backgrounds, or should we be investigating the differences in each country?

Why Study the Correlation between Culture and NSSI?Western cultures are typically known to solicit for help when it is needed. Although this is true, NSSI is still a major issue within societies.Many Eastern cultures in contrast believe that a whole group should take priority over each individual in the group. So if they do not solicit for help, but instead offer help when needed, what is their prevalence of NSSI?Are there any similarities between cultures that may be causing this issue?70

Non-suicidal self-injury in an ethnically diverse college sample (Kuentzel et al, 2012)Native AmericansCaucasian

Arab Americans and Middle Eastern IndividualsAfrican American

African American individuals reported a low number of non-suicidal self-injury.

There is an elevated risk of NSSI in Native Americans. Arab Americans as well as individuals who are Middle Eastern were also found to have low rates of NSSI behaviour.

Caucasian levels of NSSI are relatively high.

This study also discovered that individuals who identify as multiracial have a high risk for NSSI behaviour.

Taking religion into account for ethnic differences did not affect the results.

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Non-suicidal self-injury among ethnically and racially diverse emerging adults: Do factors unique to Minority experience matter (Chesin, Moster & Jeglic, 2013)?AsianCaucasianAfrican AmericanHispanic

Prevalence of NSSI was higher among Caucasian as well as Asian individuals.

Prevalence of Hispanic as well as African American individuals in engaging in NSSI behaviour is low. Less than one in ten engage in such behaviour. 72