Nonsuicidal Self‐Injury in Adolescents: Characterization of the Disorder and the Issue of Distress and Impairment

Nonsuicidal self‐injury disorder (NSSID) is a condition in need of further study to assess the validity of the potential diagnosis and its suggested criteria. This study examined the NSSID diagnosis and investigated the distress/impairment criterion by comparing community adolescents who met all criteria for NSSID (n = 186) to adolescents with five or more nonsuicidal self‐injury (NSSI) episodes (n = 314), and to a group of adolescents who met all criteria but negated that their NSSI caused them any distress or impairment, thus failing to meet criterion E (n = 29). The NSSID group delimited from the ≥ 5 NSSI group by reporting significantly more frequent and severe self‐injurious thoughts and behaviors, as well as having more experiences of negative life events and higher levels of trauma symptoms. There were also some differences between the NSSID group and adolescents without distress/impairment, which together contribute valuable information on the potential NSSID diagnosis, as well as the discussion of criterion E.     

The significance of overvaluation of shape and weight in binge eating disorder

As publication of DSM-V draws near, research is needed to validate the diagnostic scheme for binge eating disorder (BED). Shape and weight overvaluation has stimulated considerable debate in this regard, given associations with psychosocial impairment and poor treatment outcome in BED. This study sought to further explore the convergent validity and diagnostic specificity of shape and weight overvaluation in BED. A total of 160 women with BED, and 108 women with non-eating disordered psychiatric disorders were recruited from the community. Women with BED were classified as more or less severe based on a global measure of eating-related psychopathology; subsequent receiver operating characteristics analysis determined that a threshold of at least “moderate” overvaluation best predicted membership into a more severe group. BED participants with threshold overvaluation exhibited poorer psychosocial functioning than those with subthreshold overvaluation, as well as participants with other psychiatric disorders. Discriminant function analysis revealed that threshold overvaluation predicted a diagnosis of BED versus other psychiatric disorder with 67.7% accuracy. Results suggest that shape and weight overvaluation is a useful diagnostic specifier in BED. Continued research is warranted to examine its predictive validity in natural course and treatment outcome studies.     

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

Previous prevalence rates of non-suicidal self-injury (NSSI) in adolescents have varied considerably. In the present cross-sectional study, prevalence rates, characteristics and functions of NSSI were assessed in a large randomized community sample consisting of 3,060 (50.5 % female) Swedish adolescents aged 15–17 years. The suggested criteria for NSSI disorder in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition, (DSM-5) were used to assess prevalence rates with the aim of arriving at a more precise estimate. Out of the whole sample, 1,088 (35.6 %) adolescents (56.2 % female) reported at least one episode of NSSI during the last year, of which 205 (6.7 %) met suggested DSM-5 criteria for a potential NSSI disorder diagnosis. The NSSI disorder diagnosis was significantly more common in girls (11.1 % vs. 2.3 %, χ ² (1, N?=?3046) = 94.08, p?<?0.001, cOR?=?5.43, 95 % CI [3.73, 7.90]). The NSSI disorder group consisted of significantly more smokers and drug users compared to adolescents with NSSI that did not meet DSM-5 criteria for NSSI disorder, and also differed concerning demographic variables. A confirmatory factor analysis (CFA) was conducted on reported functions of NSSI, with the aim of validating Nock and Prinstein’s (Journal of Consulting and Clinical Psychology 72:885–890, 2004, Journal of Abnormal Psychology 114:140–146, 2005) four-factor model on a Swedish community sample, resulting in a close to acceptable fit. A two-factor model (social and automatic reinforcement) resulted in a slightly better fit. The most frequently reported factors were positive and negative automatic reinforcement. A majority of functions were significantly more often reported by girls than boys. The implications of the suggested DSM-5 criteria and reported functions are discussed.     

Mind the gap: assessing impairment among children affected by proposed revisions to the diagnostic criteria for oppositional defiant disorder

The Diagnostic and Statistical Manual for Mental Disorders, Fifth Edition (DSM-5) workgroup for disruptive behavior disorders is considering adopting a frequency threshold for symptoms of oppositional defiant disorder (ODD). In the present study, the impact of substituting the term "often" with a specific age-based frequency on impairment and prognosis among preschool children was tested in a longitudinal design. Mutually exclusive groups were created to identify children who met criteria for ODD based on a symptom threshold of "often," as in Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition (DSM-4), and those that met criteria for ODD based on a threshold of "1-2 times per day," which approximated the proposal for DSM-5. Comparisons of these groups to each other and to nondiagnosed peers determined the impact of changing the symptom threshold on impairment and prognosis. Close to one-third of children who met DSM-4 criteria for ODD did not meet criteria under the alternative diagnosis; African American children were overrepresented in this group. Preschoolers who met DSM-4, but not the alternative criteria, had higher rates of ODD, conduct disorder (CD), and were more impaired than their nondiagnosed peers at baseline and follow-up. Preschoolers meeting DSM-4 criteria were less impaired than children meeting the alternative ODD criteria at baseline according to parent, but not according to teacher report. No differences could be detected between those meeting DSM-4 and those meeting the alternative criteria in rate of ODD, CD, or impairment at follow-up. Among clinically referred preschool children, changing the symptom threshold for ODD could result in a sizable group of children who would no longer meet diagnostic criteria, despite demonstrating significant morbidity concurrently and prospectively.     

The Contribution of Worry Behaviors to the Diagnosis of Generalized Anxiety Disorder

Worry behaviors (i.e., overt acts to avoid or cope with worry-induced distress) have been recognized as being important in the psychopathology and treatment of generalized anxiety disorder (GAD). This study evaluated the worry behaviors criterion proposed for DSM-5 GAD, but was ultimately not adopted due to insufficient evidence. In 800 outpatients with emotional disorders (366 with GAD), most patients with GAD (92.6%) met the proposed worry behaviors criterion, which was at a rate significantly higher than other patient groups (e.g., patients with mood disorders). Patients who met the worry behaviors criterion had more severe GAD than patients who did not. The worry behaviors criterion, and 3 of its 4 constituent behaviors, were associated with no better than “fair” interrater reliability. Diagnostic reliability of GAD was not improved in cases where both interviewers agreed the worry behaviors criterion was met. The worry behaviors criterion significantly predicted DSM-5 GAD holding core GAD features constant (e.g., excessive worry), but this contribution was weak and did not appreciably improve the classification accuracy of GAD diagnostic status. Mixed support was obtained for the discriminant validity of the worry behaviors criterion in relation to mood disorders. Raising the proposed threshold of the criterion (requiring 2 instead of 1 behaviors) did not result in a substantial improvement in reliability, prediction, and classification accuracy. Although additional research is warranted (e.g., importance of worry behaviors in the treatment and natural course of GAD), the results raise questions about the role of worry behaviors in the diagnostic classification of GAD.     

An interpersonal analysis of pathological personality traits in DSM-5

The proposed changes to the personality disorder section of the Diagnostic and statistical manual of mental disorders (5th ed.) places an increased focus on interpersonal impairment as one of the defining features of personality psychopathology. In addition, a proposed trait model has been offered to provide a means of capturing phenotypic variation on the expression of personality disorder. In this study, the authors subject the proposed DSM-5 traits to interpersonal analysis using the inventory of interpersonal problems-circumplex scales via the structural summary method for circumplex data. DSM-5 traits were consistently associated with generalized interpersonal dysfunction suggesting that they are maladaptive in nature, the majority of traits demonstrated discriminant validity with prototypical and differentiated interpersonal problem profiles, and conformed well to a priori hypothesized associations. These results are discussed in the context of the DSM-5 proposal and contemporary interpersonal theory, with a particular focus on potential areas for expansion of the DSM-5 trait model.     

Emotion Differentiation as a Protective Factor Against Nonsuicidal Self-Injury in Borderline Personality Disorder

Evidence that nonsuicidal self-injury (NSSI) serves a maladaptive emotion regulation function in borderline personality disorder (BPD) has drawn attention to processes that may increase risk for NSSI by exacerbating negative emotion, such as rumination. However, more adaptive forms of emotion processing, including differentiating broad emotional experiences into nuanced emotion categories, might serve as a protective factor against NSSI. Using an experience-sampling diary, the present study tested whether differentiation of negative emotion was associated with lower frequency of NSSI acts and urges in 38 individuals with BPD who reported histories of NSSI. Participants completed a dispositional measure of rumination and a 21-day experience-sampling diary, which yielded an index of negative emotion differentiation and frequency of NSSI acts and urges. A significant rumination by negative emotion differentiation interaction revealed that rumination predicted higher rates of NSSI acts and urges in participants with difficulty differentiating their negative emotions. The results extend research on emotion differentiation into the clinical literature and provide empirical support for clinical theories that suggest emotion identification and labeling underlie strategies for adaptive self-regulation and decreased NSSI risk in BPD.     

Motivations for Self‐Injury,Affect, and Impulsivity: A Comparison of Individuals with Current Self‐Injury to Individuals with a History of Self‐Injury

Individuals who report nonsuicidal self‐injury (NSSI) are characterized by the tendency to act rashly while experiencing distress (negative urgency), the tendency to act without thinking, and endorsement of both social and affect regulation motives for the behavior. However, very little research has identified characteristics that distinguish current self‐injurers from those with a history of the behavior. The purpose of this study was to compare individuals with current self‐injury to a history of self‐injury on impulsivity‐related personality traits, motives for self‐injury, and distress. Among a sample of 429 undergraduates, 120 reported self‐injury. Among these 120 individuals, 33 endorsed self‐injury within the past month, with a mean frequency of 4.77 acts of NSSI. Within the self‐injury group, current self‐injurers reported higher endorsement of affect regulation motives for NSSI, and higher levels of current negative affect than individuals with a history of self‐injury. There were no differences between current and former self‐injurers on measures of impulsivity, endorsement of social motives for NSSI, or positive affect. We propose that individuals who use NSSI to regulate negative affect may be more likely to repeatedly engage in this behavior over time.     

Prospective prediction of nonsuicidal self-injury: a 1-year longitudinal study in young adults

Nonsuicidal self-injury (NSSI) has become a significant public health problem. Although numerous studies have examined cross-sectional psychological correlates of NSSI, there has been little research examining predictors of NSSI over time. The present study examined cross-sectional and longitudinal correlates of NSSI in 81 young adult self-injurers (M age = 19, 74.1% female, 51.9% Caucasian), 51 of whom were followed up 1 year later. At baseline, participants completed self-report measures of NSSI, Axis-I disorders, borderline personality disorder (BPD), and impulsivity, as well as an implicit measure of NSSI attitudes and identity. One year later, participants completed a Timeline Followback Method whereby they indicated their engagement in NSSI over the previous 12 months. Analyses replicated many known cross-sectional correlates of NSSI, including symptoms of several Axis-I disorders and BPD. However, many of these same variables failed to predict the course of NSSI over the 1-year follow-up. The only variables to prospectively predict NSSI were past NSSI (i.e., frequency, methods, and recency of NSSI), participants’ behavioral forecast of their engagement in future NSSI, and BPD features. Findings suggest that many cross-sectional correlates of NSSI may not be useful for predicting subsequent NSSI. Instead, NSSI severity and BPD features appear to best predict continued engagement in NSSI.     

Validation of Self-Report Impairment Measures for Section III Obsessive–Compulsive and Avoidant Personality Disorders

This study examined the validity of newly developed disorder-specific impairment scales (IS), modeled on the Level of Personality Functioning Scale, for obsessive–compulsive (OCPD) and avoidant (AvPD) personality disorders. The IS focused on content validity (items directly reflected the disorder-specific impairments listed in DSM-5 Section III) and severity of impairment. A community sample of 313 adults completed personality inventories indexing the DSM-5 Sections II and III diagnostic criteria for OCPD and AvPD, as well as measures of impairment in the domains of self- and interpersonal functioning. Results indicated that both impairment measures (for AvPD in particular) showed promise in their ability to measure disorder-specific impairment, demonstrating convergent validity with their respective Section II counterparts and discriminant validity with their noncorresponding Section II disorder and with each other. The pattern of relationships between scores on the IS and scores on external measures of personality functioning, however, did not indicate that it is useful to maintain a distinction between impairment in the self- and interpersonal domains, at least for AvPD and OCPD.     

Non-suicidal self-injury and identity distress in Flemish adolescents: Exploring gender differences and mediational pathways

There is an increasing amount of research that examines non-suicidal self-injury (NSSI) in relation to identity formation in adolescents. However, little or no research to date has explored associations between NSSI and identity distress in specific domains. To address this shortcoming, we assessed NSSI, identity distress, anxiety, and depression using self-report questionnaires in 568 high school students. Gender differences in NSSI were found with lifetime prevalence of NSSI being twice as high in females as compared to males. Gender differences in terms of identity domains were also significant; adolescent females showed higher levels of distress in the identity domains of career goals, friendship, and group loyalties as compared to males. Adolescents engaging in NSSI showed higher distress in domains of long-term goals, friendship, sexual orientation and behavior, values and beliefs. Results indicated that it was not distress in specific domains as such but the impairment due to daily impact of identity distress that explained additional variance in lifetime prevalence of NSSI above and beyond gender, age, depression, and anxiety. We also demonstrated that gender differences in lifetime prevalence of NSSI were mediated by differences in such identity impairment. Clinical implications of these findings are discussed.     

Does marriage protect older people from distress? The role of equity and recency of bereavement

The association between marital status and distress was examined in a largely neglected group, namely older people (65 and older; N = 1,649). In this 2-wave study, married persons were less distressed than single persons, but perceived equity within the marriage and recency of bereavement qualified these findings. Married persons who felt inequitably treated were more distressed than persons who had always been single. Married persons reported less distress than recently (= 2 years ago) widowed persons, but only equitably treated married persons reported less distress than persons widowed for more than 2 years. Increased distress between the 2 waves occurred in recently widowed persons, and there was a decrease in distress in persons who were widowed shortly before the 1st wave. No gender effects were found.     

Frequency of Nonsuicidal Self‐Injury in Adolescents: Differences in Suicide Attempts,Substance Use,and Disordered Eating

The relationship between frequency of nonsuicidal selfinjury (NSSI) and suicide attempts, substance use, and disordered eating was assessed in a community sample of 4,839 adolescents, 922 of whom reported NSSI in the past year. It was expected that the engagement in risk behaviors would significantly increase as NSSI frequency increased. Participants completed the Youth Risk Behavior Survey (Centers for Disease Control and Prevention, 2009) and were subdivided into five NSSI frequency groups: none, 1 time, 2–3 times, 4–5 times, and 6 or more times. A one‐way MANOVA found significant mean differences for all variables across NSSI frequency groups. The no NSSI group was significantly lower than all other groups on all variables. For suicide attempts, all frequency groups were significantly different from each other, with attempt frequency increasing with each increase in NSSI frequency. The six or more group reported significantly more substance use and disordered eating than all other groups. Overall, adolescents with more frequent NSSI represent a group at risk for concurrent unhealthy behaviors and suicide attempts.     

Assessing the Functions of Non-suicidal Self-injury: Psychometric Properties of the Inventory of Statements About Self-injury (ISAS)

The present study reports the psychometric properties of the Inventory of Statements About Self-injury (ISAS), a measure designed to comprehensively assess the functions of non-suicidal self-injury (NSSI). The ISAS assesses 13 functions of NSSI, as well as the frequency of 12 NSSI behaviors. The ISAS was administered to 235 young adults from a college population who had performed at least one NSSI behavior. Consistent with previous research, ISAS functions comprised two factors representing interpersonal and intrapersonal functions. In addition, the ISAS factors exhibited excellent internal consistency and expected correlations with both clinical constructs (e.g., borderline personality disorder, suicidality, depression, anxiety) and contextual variables (e.g., tendency to self-injure alone). Findings support the reliability and validity of the ISAS. The ISAS may be useful in research and treatment contexts as a comprehensive measure of NSSI functions.     

Significance of overvaluation of shape and weight in an ethnically diverse sample of obese patients with binge-eating disorder in primary care settings

Undue influence of shape or weight on self-evaluation--referred to as overvaluation--is a core feature across eating disorders, but is not a diagnostic requirement for binge-eating disorder (BED). This study examined overvaluation of shape/weight in ethnically diverse obese patients with BED seeking treatment in primary care. Participants were a consecutive series of 142 (105 female and 37 male) participants with BED; 43% were Caucasian, 37% were African-American, 13% were Hispanic-American, and 7% were of "other" ethnicity. Participants categorized with overvaluation (N=97; 68%) versus without clinical overvaluation (N=45; 32%) did not differ significantly in ethnicity/race, age, gender, body mass index, or binge-eating frequency. The overvaluation group had significantly greater levels of eating disorder psychopathology, poorer psychological functioning (higher depression, lower self-esteem), and greater anxiety disorder co-morbidity than the group who did not overvalue their shape/weight. The greater eating disorder and psychological disturbance levels in the overvaluation group relative to the non-overvaluation group persisted after controlling for psychiatric co-morbidity. Our findings, based on an ethnically diverse series of patients seeking treatment in general primary care settings, are consistent with findings from specialist clinics and suggest that overvaluation does not simply reflect concerns commensurate with being obese or with frequency of binge-eating, but is strongly associated with heightened eating-related psychopathology and psychological distress. Overvaluation of shape/weight warrants consideration as a diagnostic specifier for BED as it provides important information about severity.     

Profiles of Non-Suicidal Self-Injurers and Associated Patterns of Alcohol Use

This study used latent variable mixture modeling (LVMM) with a combined sample of undergraduates and internet users who endorsed non-suicidal self-injury (NSSI; N?=?440) to identify profiles of non-suicidal self-injurers. LVMM results revealed four distinct subtypes (“Experimental NSSI,” “Mild NSSI,” “Multiple Functions/Anxious,” and “Automatic Functions/Suicidal” groups) that were similar to those found in a prior study of undergraduates Klonsky and Olino (Journal of Consulting and Clinical Psychology 76:22-27, 2008), with an additional fifth “Multi-method.” ANOCOVAs and logistic regressions showed the first four groups differed on aspects of psychopathology in a similar fashion to the previous study. Specifically, the Experimental and Mild NSSI groups had the lowest levels of psychopathology, and the AF/Suicidal group had higher levels of psychopathology than the first three groups except for anxiety, which was higher for the MF/Anxious group. The additional Multi-method group was found to have higher levels of psychopathology than all other groups, but not significantly different from the MF/Anxious group. With regard to alcohol use and drinking motives, the MF/Anxious group had the highest level of hazardous drinking and drinking motives related to coping with depression and anxiety, enhancement, and conformity. The other four groups were not differentiated from one another on any drinking variable. Findings suggest that NSSI may be better conceptualized as a heterogeneous syndrome in clinical and research settings, with one sub-group being more at-risk for hazardous alcohol use.     

DSM-IV criteria for generalized anxiety disorder in older adults: distinguishing the worried from the well

This study compared 36 older adults with generalized anxiety disorder (GAD), 22 older adults with subsyndromal anxiety symptoms, and 32 normal controls on criteria of the Diagnostic and Statistical Manual of Mental Disorders (4th ed.) for GAD. GAD patients reported more frequent and uncontrollable worry, somewhat different worry content, higher prevalence of most associated symptoms, and more distress or impairment than the subsyndromal group or normal controls. Individuals with subsyndromal anxiety reported more excessive, frequent, and uncontrollable worry than asymptomatic individuals, along with more sleep disturbance, fatigue, and distress or impairment. Results indicate that the key features of late-life GAD are distress and impairment, frequency and uncontrollability of worry, muscle tension, and sleep disturbance and that clinicians treating older adults with GAD should monitor and treat residual symptoms.     

Frequency and recency effects on response biasing in a pseudo-perceptual task

The pseudo-recognition technique provides an ingenious method of evaluating the influence of response biasing variables. This study tests the effects of recency on low and medium frequency words using the pseudo-recognition procedure. It was found that under short recency conditions the thresholds of medium and low frequency words did not differ, while under longer recency conditions the low frequency words had significantly lower thresholds than medium frequency words.     

Sex bias in the diagnosis of personality disorders: A different approach

There has been considerable controversy regarding a possible sex bias in the diagnosis of personality disorders (PDs). However, prior research has at times confused a bias within clinicians who fail to adhere to the diagnostic criteria with a bias within the diagnostic criteria. Rather than assess whether females are more likely than males to be diagnosed with a respective disorder, the current study assesses whether the thresholds for the diagnosis of female-typed PDs are lower than the thresholds for male-typed PDs. Subjects completed two self-report inventories for the DSM-III-R personality disorders, and three inventories that assessed 30 aspects of personality dysfunction organized with respect to social dysfunction, occupational dysfunction, and personal distress. There was no indication that the diagnostic thresholds for personality disorders that occur more often in females is lower than the thresholds for the personality disorders that occur more often in males. The implications of these findings for the issue of sex biased diagnoses are discussed.