Mitchell J. Prinstein

Non-suicidal self-injury among adolescents: Diagnostic correlates and relation to suicide attempts

Non-suicidal self-injury (NSSI) is a prevalent behavioral problem, yet many fundamental aspects of NSSI remain unknown. This case series study reports on the diagnostic correlates of adolescents with a recent history of NSSI and examines the relation between NSSI and suicide attempts. Data are from clinical interviews with 89 adolescents admitted to an adolescent psychiatric inpatient unit who engaged in NSSI in the previous 12 months. Results revealed that 87.6% of adolescents engaging in NSSI met criteria for a DSM-IV Axis I diagnosis (M=3.0, S.D.=2.2, range=0 to 8 diagnoses), including externalizing (62.9%), internalizing (51.7%), and substance use (59.6%) disorders. Most adolescents assessed also met criteria for an Axis II personality disorder (67.3%). Overall, 70% of adolescents engaging in NSSI reported a lifetime suicide attempt and 55% reported multiple attempts. Characteristics of NSSI associated with making suicide attempts included a longer history of NSSI, use of a greater number of methods, and absence of physical pain during NSSI. These findings demonstrate the diagnostic heterogeneity of adolescents engaging in NSSI, highlight the significant overlap between NSSI and suicide attempts, and provide a point of departure for future research aimed at elucidating the relations between non-suicidal and suicidal self-injury.

A functional approach to the assessment of self-mutilative behavior.

This study applied a functional approach to the assessment of self-mutilative behavior (SMB) among adolescent psychiatric inpatients. On the basis of past conceptualizations of different forms of self-injurious behavior, the authors hypothesized that SMB is performed because of the automatically reinforcing (i.e., reinforced by oneself; e.g., emotion regulation) and/or socially reinforcing (i.e., reinforced by others; e.g., attention, avoidance-escape) properties associated with such behaviors. Data were collected from 108 adolescent psychiatric inpatients referred for self-injurious thoughts or behaviors. Adolescents reported engaging in SMB frequently, using multiple methods, and having an early age of onset. Moreover, the results supported the structural validity and reliability of the hypothesized functional model of SMB. Most adolescents engaged in SMB for automatic reinforcement, although a sizable portion endorsed social reinforcement functions as well. These findings have direct implications for the understanding, assessment, and treatment of SMB.

Prediction of Posttraumatic Stress Symptoms in Children After Hurricane Andrew

The authors used an integrative conceptual model to examine the emergence of posttraumatic stress disorder (PTSD) symptoms in 568 elementary school-age children 3 months after Hurricane Andrew. The model included 4 primary factors: Exposure to Traumatic Events, Child Characteristics, Access to Social Support, and Childrens Coping. Overall, 62% of the variance in childrens self-reported PTSD symptoms was accounted for by the 4 primary factors, and each factor improved overall prediction of symptoms when entered in the analyses in the order specified by the conceptual model. The findings suggest that the conceptual model may be helpful to organize research and intervention efforts in the wake of natural disasters.

Contextual Features and Behavioral Functions of Self-Mutilation Among Adolescents

Adolescent self-mutilative behavior (SMB) is a pervasive and dangerous problem, yet factors influencing the performance of SMB are not well understood. The authors examined the contextual features and behavioral functions of SMB in a sample of 89 adolescent psychiatric inpatients. SMB typically was performed impulsively, in the absence of physical pain, and without the use of alcohol or drugs. Moreover, analyses supported the construct validity of a functional model in which adolescents reported engaging in SMB for both automatic and social reinforcement. Considering the functions of SMB clarified the relations between SMB and other clinical constructs reported in previous studies such as suicide attempts, posttraumatic stress, and social concerns and has direct implications for the assessment and treatment of SMB.

Revealing the Form and Function of Self-Injurious Thoughts and Behaviors: A Real-Time Ecological Assessment Study among Adolescents and Young Adults

Self-injurious behaviors are among the leading causes of death worldwide. However, the basic nature of self-injurious thoughts and behaviors (SITBs) is not well understood because prior studies have relied on long-term, retrospective, aggregate, self-report assessment methods. The authors used ecological momentary assessment methods to measure suicidal and nonsuicidal SITBs as they naturally occur in real time. Participants were 30 adolescents and young adults with a recent history of self-injury who completed signal- and event-contingent assessments on handheld computers over a 14-day period, resulting in the collection of data on 1,262 thought and behavior episodes. Participants reported an average of 5.0 thoughts of nonsuicidal self-injury (NSSI) per week, most often of moderate intensity and short duration (1-30 min), and 1.6 episodes of NSSI per week. Suicidal thoughts occurred less frequently (1.1 per week), were of longer duration, and led to self-injurious behavior (i.e., suicide attempts) less often. Details are reported about the contexts in which SITBs most often occur (e.g., what participants were doing, who they were with, and what they were feeling before and after each episode). This study provides a first glimpse of how SITBs are experienced in everyday life and has significant implications for scientific and clinical work on self-injurious behaviors.

Longitudinal Study of Nonsuicidal Self-Injury Among Young Adolescents: Rates, Correlates, and Preliminary Test of an Interpersonal Model

This study examined rates, correlates and an interpersonal model of nonsuicidal self-injury (NSSI) among a sample of 508 sixth, seventh, and eighth graders. Questionnaires assessing NSSI, related health-risk behaviors, and relationships with parents were administered two times over an 11-month period. Overall, 7.5% reported engaging in NSSI within the past year with no significant differences across genders, ethnicities, or grade. Those engaging in NSSI were more likely to report having smoked cigarettes, taken drugs, and engaged in maladaptive eating behaviors. Consistent with an interpersonal model, those engaging in NSSI reported significant increases in the quality of their relationships with fathers over time. Clinical implications include considering the role of family members in efforts to prevent and treat NSSI.

Longitudinal Trajectories and Predictors of Adolescent Suicidal Ideation and Attempts Following Inpatient Hospitalization

Remarkably little is known regarding the temporal course of adolescent suicidal ideation and behavior, the prediction of suicidal attempts from changes in suicidal ideation, or the prediction of suicidal attempts after accounting for suicidal ideation as a predictor. A sample of 143 adolescents 12-15 years old was assessed during psychiatric inpatient hospitalization and again at 3, 6, 9, 15, and 18 months postdischarge through a series of structured interviews and parent- and adolescent-reported instruments. Symptoms of depression, posttraumatic stress disorder, externalizing psychopathology, hopelessness, and engagement in several forms of self-injurious/suicidal behaviors (i.e., suicide threats/gestures, plans, nonsuicidal self-injury [NSSI]) were assessed. Latent growth curve analyses revealed a period of suicidal ideation remission between baseline and 6 months following discharge, as well as a subtle period of suicidal ideation reemergence between 9 and 18 months postdischarge. Changes in suicidal ideation predicted suicide attempts. After accounting for the effects of suicidal ideation, baseline suicide threats/gestures also predicted future suicide attempts. Higher adolescent-reported depressive symptoms, lower parent-reported externalizing symptoms, and higher frequencies of NSSI predicted weaker suicidal ideation remission slopes. Findings underscore the need for more longitudinal research on the course of adolescent suicidality.

Peer Functioning, Family Dysfunction, and Psychological Symptoms in a Risk Factor Model for Adolescent Inpatients' Suicidal Ideation Severity

Examined models of suicidal ideation severity that include two psychosocial risk factors (i.e., peer and family functioning) and four domains of psychological symptoms (i.e., generalized anxiety, depression, conduct problems, and substance abuse/dependence). Participants were 96 psychiatric inpatients (32 boys, 64 girls), ages 12 to 17, who were hospitalized because of concerns of suicidality. Adolescents completed a structured diagnostic interview, measures of suicidal ideation, and several dimensions of family and peer functioning. Results supported a model in which greater levels of perceived peer rejection and lower levels of close friendship support were associated directly with more severe suicidal ideation. In addition, indirect pathways included deviant peer affiliation and global family dysfunction related to suicidal ideation via substance use and depression symptoms. The results are among the first to demonstrate relations between suicidal ideation and several areas of adolescent peer functioning, as well as divergent processes for peer and family predictors of suicidal ideation.

Introduction to the special section on suicide and nonsuicidal self-injury: a review of unique challenges and important directions for self-injury science.

Self-injurious behaviors, including nonsuicidal self-injury (NSSI) and suicidal behaviors, are remarkably prevalent and woefully understudied. This area of research involves numerous methodological, ethical, and practical challenges that have limited progress in understanding some of the most basic characteristics and correlates of self-injurious behavior. To date, relatively little data are available to develop empirically based preventions or interventions, and no empirically supported treatments currently are available to reduce NSSI or suicidality in most populations. The articles in this special section offer examples of methodologically innovative, theoretically based work that address these research needs. Articles in this special section include studies of functional models of NSSI, studies that examine more distal risk factors for NSSI, and studies of suicidality. A brief review of current research in these areas is offered.

Clarifying the role of pain tolerance in suicidal capability

Joiners (2005) interpersonal-psychological theory of suicide hypothesizes that painful and provocative events increase pain tolerance. The theory further proposes that increased pain tolerance represents one component of increased suicidal capability. Although initial studies have been consistent with this model, several key aspects remain untested. In 67 undergraduates, we investigated associations among painful and provocative events, nonsuicidal self-injury, acquired capability for suicide, and pain tolerance, threshold, and perceived intensity. Results were highly consistent with the interpersonal-psychological theory: a multiple mediation model specified that pain tolerance - but not other pain variables - accounted for significant variance within the association between painful and provocative events and acquired capability for suicide. These results held even when the pain tolerance item was removed from the suicidal capability questionnaire. Results also supported the interpersonal-psychological theory hypothesis that nonsuicidal self-injury represents an important painful and provocative event that increases suicidal capability. Specifically, participants with a history of nonsuicidal self-injury displayed increased suicidal capability and decreased pain perception. Overall, these results indicate that pain tolerance plays an important and specific role in suicidal capability.