Interoceptive Deficits,Nonsuicidal Self‐Injury,and Suicide Attempts Among Women with Eating Disorders

People with eating disorders (ED s) have an elevated risk for both nonsuicidal self‐injury (NSSI ) and suicide compared to the general population. This study tests two theoretically derived models examining interoceptive deficits as a risk factor for NSSI , and examining interoceptive deficits, NSSI , fearlessness about death, and pain tolerance as risk factors for suicide. Ninety‐six adult, treatment‐seeking women with ED s completed self‐report questionnaires at a single time point. Interoceptive deficits were significantly associated with NSSI , and NSSI was in turn associated with both pain tolerance and fearlessness about death. Further, pain tolerance was in turn associated with past suicide attempts, although fearlessness about death was not associated with suicide attempts. Interoceptive deficits had a direct association with fearlessness about death but not pain tolerance. Results regarding the relation between interoceptive deficits and suicide attempts were mixed, yet overall suggest that interoceptive deficits are related to suicide attempts largely indirectly, through the effects of mediating variables such as NSSI , fearlessness about death, and pain tolerance. Results suggest that interoceptive deficits and pain tolerance merit further investigation as potential risk factors for fatal and nonfatal self‐harm among individuals with ED s.     

In Eating‐Disordered Inpatient Adolescents,Self‐Criticism Predicts Nonsuicidal Self‐Injury

We examined the role of depressive traits—self‐criticism and dependency—in nonsuicidal self‐injury (NSSI) and suicidal ideation among inpatient adolescents with eating disorders. In two studies (N = 103 and 55), inpatients were assessed for depressive traits, suicidal ideations, and NSSI. In Study 2, motivation for carrying out NSSI was also assessed. In both studies, depression predicted suicidal ideation and self‐criticism predicted NSSI. In Study 2, depression and suicidal ideation also predicted NSSI. The automatic positive motivation for NSSI was predicted by dependency and depressive symptoms, and by a two‐way interaction between self‐criticism and dependency. Consistent with the “self‐punishment model,” self‐criticism appears to constitute a dimension of vulnerability for NSSI.     

Childhood Abuse,Nonsuicidal Self‐Injury,and Suicide Attempts: An Exploration of Gender Differences in Incarcerated Adults

The relationship between types of childhood abuse, suicide attempts, and nonsuicidal self‐injury (NSSI) was examined in a sample of 415 incarcerated adults (268 men, 147 women). Men and women were equally likely to experience childhood abuse, although women were more likely to report sexual abuse and men were more likely to report emotional neglect. Sexual abuse was the only type of abuse found to predict NSSI and suicide attempts in women. For men, physical abuse and physical neglect were significant predictors of NSSI and suicide attempts, respectively. Gender differences exist and should be examined in future research in this area.     

Psychiatric and Self‐Injury Profiles of Adolescent Suicide Attempters versus Adolescents Engaged in Nonsuicidal Self‐Injury

To better delineate the unique correlates of self‐injurious behaviors (SIB), psychiatric profiles of mutually exclusive groups of adolescents who made a suicide attempt (SA) versus those engaged in nonsuicidal self‐injury (NSSI) were examined. Contrary to hypotheses, the NSSI group endorsed earlier onsets of SIB and suicidal ideation (SI), as well as higher rates of depression and anxiety compared with their SA counterparts. Future work is warranted to understand the role of SI, including duration of SI and anxiety in the development of NSSI, and to identify risk and resiliency factors useful in predicting an adolescent's SIB status.     

Examining Intent to Die and Methods for Nonsuicidal Self‐Injury and Suicide Attempts

Nonsuicidal self‐injury (NSSI) is linked to suicidal behavior and future suicide attempts, but the process of NSSI‐to‐suicide attempts remains unclear. Additionally, little is known about how having a history of NSSI may relate to reports of intent to die during a suicide attempt. The current study examined methods of NSSI and suicide attempts, as well as intent to die, in a sample of 1,232 young adults, 54 of whom reported at least one suicide attempt. Cutting and overdose were the predominant methods of NSSI and suicide attempts, respectively, with the two often co‐occurring. Individuals with both NSSI and suicide attempt history were significantly more likely to report an intent to die than those with suicide attempt history only.     

Nonsuicidal Self‐Injury Is Predictive of Suicide Attempts Among Individuals with Mood Disorders

Nonsuicidal self‐injury (NSSI) prior to age 18 was evaluated as a risk factor for adulthood suicide attempt (SA). Archival data from 222 mood‐disordered participants were analyzed using multivariate Cox proportional hazards analysis. Participants with a youth SA were excluded. The hazards of SA among adult participants with a history of youth NSSI were twice than those of mood‐disordered participants without youth NSSI (hazard ratio = 2.00, 95% confidence interval = 1.16–3.44, p = .01). Moreover, participants who had both youth and adult NSSI attempted suicide significantly earlier than participants who began NSSI as an adult. Youth NSSI is associated with persistent, elevated SA risk in adulthood.     

Self‐Criticism as a Transdiagnostic Process in Nonsuicidal Self‐Injury and Disordered Eating: Systematic Review and Meta‐Analysis

Nonsuicidal self‐injury (NSSI) and disordered eating (DE) are highly comorbid and may be regarded as belonging to a spectrum of self‐harm behaviors. We investigated self‐criticism as a transdiagnostic correlate of these behaviors, in keeping with etiological theories of both NSSI and DE. We reviewed the literature and meta‐analyzed the relation of self‐criticism to both NSSI (15 studies; 17 effect sizes) and DE (24 studies; 29 effect sizes). Results showed equivalent, moderate‐to‐large effects for the relation of self‐criticism to NSSI (r = .38; CI: .29–.46) and DE (r = .40; CI: .34–.45). The relation of NSSI to self‐criticism generalized across multiple potential moderators. DE behavior type moderated the relation of self‐criticism to DE, with a stronger relation emerging for purging than restriction. Findings support self‐criticism as a possible candidate for transdiagnostic pathways to self‐harm.     

Trajectories of Suicide Ideation,Nonsuicidal Self‐Injury,and Suicide Attempts in a Nonclinical Sample of Military Personnel and Veterans

Nonsuicidal self‐injury (NSSI) is a risk factor for suicide attempts, but little is known about NSSI among military personnel and veterans, or about the temporal sequencing of NSSI relative to suicide ideation and attempts. This study evaluates trajectories of suicide ideation, NSSI, and suicide attempts in a sample of 422 military personnel and veterans. Of those with a history of NSSI, 77% also experienced suicide ideation. Suicide ideation emerged before NSSI (67%) more often than the reverse (17%). Of those with a history of suicide attempt, 41% also engaged in NSSI. NSSI emerged prior to the first suicide attempt (91%) more often than the reverse (9%). The length of time from suicide ideation to suicide attempt was longer for those who first engaged in NSSI (median = 3.5 years) compared with those who did not engage in NSSI (median = 0.0 years), Wald χ²(1) = 11.985, p = .002. Age of onset was earlier for participants reporting NSSI only compared with those reporting both NSSI and suicide attempts (16.71 vs. 22.08 years), F(1, 45) = 4.149, p = .048. NSSI may serve as a “stepping stone” from suicide ideation to attempts for 41% of those who attempt suicide.     

Predicting Persistence of Nonsuicidal Self‐Injury in Suicidal Adolescents

Prospective predictors of persistent nonsuicidal self‐injury (NSSI) were examined in adolescents admitted to an inpatient psychiatric unit for suicidal behaviors and followed naturalistically for 6 months. Seventy‐one (77%) participants reported NSSI at baseline, and 40 (56%) persisted at the 6 month follow‐up. Those who endorsed automatic positive reinforcement (APR) as the predominant reason for NSSI were more likely to persist in NSSI. Depression over follow‐up, but not at baseline, also predicted persistence. These results suggest that helping high‐risk adolescents to identify alternative ways of generating emotion(s) to counter the effects of APR that may accompany NSSI should be a high priority treatment target.     

Risk‐Related and Protective Correlates of Nonsuicidal Self‐Injury and Co‐Occurring Suicide Attempts among Incarcerated Women

Individual and environmental correlates of nonsuicidal self‐injury (NSSI) and co‐occurring suicide attempts (SA) among incarcerated women (N = 104) were examined. Participants completed measures of putative risk and protective factors, including coping styles, childhood maltreatment, and hopelessness. Results indicated that active coping was uniquely, negatively associated with the presence and frequency of NSSI, whereas avoidant coping and childhood physical/emotional abuse were positively associated with NSSI frequency. Conversely, among women with a history of NSSI, hopelessness was uniquely, positively associated with the presence and frequency of SA. Further, childhood sexual abuse was associated with the presence of SA, while physical/emotional abuse was associated with SA frequency. Hopelessness was more strongly related to SA frequency than NSSI frequency. These findings help disentangle the unique risk and protective factors for NSSI and co‐occurring SA in incarcerated samples.     

Nonsuicidal Self‐Injury,Stress, and Self‐Differentiation

The authors surveyed 458 young adults and examined the relationships among stress, self‐differentiation, and nonsuicidal self‐injury (NSSI). They conducted multiple regression analyses to explore whether characteristics of self‐differentiation (i.e., emotional reactivity and “I position”) were related to NSSI after controlling for the effects of stress, as well as whether emotional reactivity and I position served as mediators in the stress–NSSI relationship. I position and emotional reactivity both contributed statistically significant variance to NSSI after accounting for stress. Moreover, both I position and emotional reactivity served as partial mediators in the stress–NSSI relationship. The authors discuss counseling and research implications.     

Functions of Nonsuicidal Self‐Injury Are Differentially Associated with Suicide Ideation and Past Attempts among Childhood Trauma Survivors

Research into factors for suicide has revealed relations between trauma exposure and suicidality (e.g., Bridge, Goldstein, & Brent, 2006 ; Joiner, Sachs‐Ericson, Wingate, Brown, Anestis, & Selby, 2007 ) wherein painful and provocative experiences (e.g., nonsuicidal self‐injury [NSSI]) are an important link (e.g., Van Orden, Witte, Cukrowicz, Braithwaite, Selby, & Joiner, 2010 ; Smith, 2013 ). No prior research has assessed the relationship between functions of NSSI and suicidality among childhood trauma survivors. Participants who endorsed childhood trauma exposure (N = 121; M_age = 18.69, range 18–22) completed measures of posttraumatic stress disorder (PTSD) symptoms, NSSI, and suicidality. Multiple regressions assessing whether the four functions of NSSI predicted suicide ideation and past attempts after controlling for PTSD symptom severity found that only social negative reinforcement was associated with SI ( = .304, SE = .243, t = 2.23, p = .028), while only automatic negative reinforcement was associated with past attempts ( = .470, SE = .066, t = 2.25, p = .028). Findings highlight the importance of assessing NSSI functions when assessing suicidality among trauma survivors.     

Nonsuicidal Self-injury,Suicide Planning,and Suicide Attempts Among High-risk Adolescents Prior to Psychiatric Hospitalization

Research on Child and Adolescent Psychopathology - The purpose of this study was to understand the trajectories of nonsuicidal self-injury (NSSI) and suicide plans (SP) in the 90 days...     

Nonsuicidal Self‐Injury among Adolescents: A Training Priority for Primary Care Providers

Primary care providers were surveyed to determine how prepared they feel to address nonsuicidal self‐injury (NSSI) among adolescents, their interest in training on NSSI, and factors associated with routinely asking about NSSI when providing health supervision. Participants included family medicine physicians (n = 260), pediatricians (n = 127), family nurse practitioners (n = 96), and pediatric nurse practitioners (n = 54). Almost 50% felt unprepared to address NSSI, and over 70% wanted training in this area. Overall, relative to other areas of mental health care, clinicians felt least prepared to address and wanted more training on NSSI. Just 27% reported they routinely inquired about NSSI during health supervision. Factors associated with routinely asking about NSSI were identifying as female (OR = 2.37; 95% CI = 1.25–4.49), feeling better prepared to address NSSI (OR = 1.51; 95% CI = 1.04–2.20), and more frequently using a psychosocial interview to identify adolescents in distress (OR = 1.23; 95% CI = 1.02–1.48). Teaching clinicians to assess NSSI within a psychosocial interview may increase screening for and identification of the behavior among adolescents in primary care.     

Similarities and Differences in the Functions of Nonsuicidal Self‐Injury (NSSI) and Sex as Self‐Injury (SASI)

Differences and similarities were studied in the functions of two different self‐injurious behaviors (SIB): nonsuicidal self‐injury (NSSI) and sex as self‐injury (SASI). Based on type of SIB reported, adolescents were classified in one of three groups: NSSI only (n = 910), SASI only (n = 41), and both NSSI and SASI (n = 76). There was support for functional equivalence in the two forms of SIB, with automatic functions being most commonly endorsed in all three groups. There were also functional differences, with adolescents in the SASI only group reporting more social influence functions than those with NSSI only. Adolescents reporting both NSSI and SASI endorsed the highest number of functions for both behaviors. Clinical implications are discussed, emphasizing the need for emotion regulation skills.     

How Many Times and How Many Ways: The Impact of Number of Nonsuicidal Self‐Injury Methods on the Relationship Between Nonsuicidal Self‐Injury Frequency and Suicidal Behavior

Several variables have been proposed as heavily influencing or explaining the association between nonsuicidal self‐injury (NSSI) and suicidal behavior. We propose that increased comfort with bodily harm may serve as an incrementally valuable variable to consider. We sought to indirectly test this possibility by examining the moderating role of number of NSSI methods utilized on the relationship between NSSI frequency and lifetime number of suicide attempts, positing that increased variability in methods would be indicative with a greater general comfort with inflicting harm upon one's own body. In both a large sample of emerging adults (n = 1,317) and a subsample with at least one prior suicide attempt (n = 143), results were consistent with our hypothesis. In both samples, the interaction term was significant, with the relationship between NSSI frequency and suicidal behavior increasing in magnitude from low to mean to high levels of NSSI methods. Although frequency of NSSI is robustly associated with suicidal behavior, the magnitude of that relationship increases as an individual engages in a wider variety of NSSI methods. We propose that this may be due to an increased comfort with the general concept of damaging one's own body resulting from a broader selection of methods for self‐harm.     

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 Importance of High Distress Tolerance in the Relationship between Nonsuicidal Self‐Injury and Suicide Potential

Research has indicated that nonsuicidal self‐injury (NSSI) and suicidal behavior are strongly related to one another, with a sizable portion of individuals with a history of NSSI also reporting a history of nonlethal suicide attempts. Nonetheless, little research has examined possible moderators of this relationship. One potentially important construct is distress tolerance (DT), which has been shown to be negatively associated with NSSI and positively associated with the acquired capability for suicide. In this study, 93 adult inpatients (54.8% male) receiving treatment for substance use disorders completed a structured interview assessing prior suicidal behavior and questionnaires assessing DT, NSSI, and psychopathology. Results indicated that DT moderates the relationship between NSSI frequency (but not number of NSSI methods) and suicide potential (a continuum ranging from no prior suicidal behavior to suicidal behavior with minimal bodily harm to highly lethal suicidal behavior), ΔR² = .04; p < .023; f² = .06, with this relation increasing in strength at higher levels of DT. These results are consistent with an emerging line of research indicating that high levels of DT facilitate suicidal behavior in at‐risk populations and suggest that the capacity to tolerate aversive physiological and affective arousal might be vital to engagement in serious or lethal suicidal behavior.