352 Research Proposal Final Bickford Williams

Running head: nON-SUICIDAL SELF-HARM 1

Non-Suicidal Self-Harm and Reported Pain Management: A Research Proposal

Billie Bickford Williams

Fayetteville State University

nON-SUICIDAL SELF-HARM 2

Table of Contents

Abstract................................................................................................................................3

Method.................................................................................................................................7

Participants......................................................................................................................7

Material............................................................................................................................7

Procedure.........................................................................................................................7

Results..................................................................................................................................9

Discussion..........................................................................................................................10

Appendix A........................................................................................................................15

Questionnaire.................................................................................................................15

Appendix C........................................................................................................................16

Comparative Pain Scale.................................................................................................16


Abstract

At the root of Non-Suicidal Self-harm is the stigma and mystery of why the sufferers

engage in behavior such as cutting or burning themselves. The common attitude of current

psychological practitioners is to approach NSSI as a symptom of other disorders such as

depression or borderline personality disorder. This research proposes to determine if there is a

benefit that self-harm provides; chiefly emotional pain management. Further the proposed data

will be useful in many other areas of study regarding self-harm.


Non-Suicidal Self-Harm and Reported Pain Management: A Research Proposal

Non-suicidal self-injury is an act of harming oneself performed by an estimated 7 to 14%

of adolescents as reported by Wilkinson and Goodyear in 2011. Cohen estimates the number as

high as 23% of the “general population” (2014, p. 10). There has been a greater level of

awareness of non-suicidal self-injury (NSSI) in the mental health community today when

compared to years past. Whitlock, Powers and Eckenrode discovered more than 400 message

boards seeking information or help with self-harm (2011). However, in the DSM-V it has only

been referenced as a characteristic of other issues such as borderline personality disorder (Osuch,

Ford, Wrath, Bartha, & Neufeld, 2014) (Cohen, 2014) (In-Albon, Ruf, & Schmid, 2013). There

have been recent hypotheses which maintain the need for NSSI to “be studied independent of

other diagnoses” (Westlund Schreiner, Klimes-Dougan, & Begnal, 2015, p. 381). The largest

portion of research in the last fifteen years has been regarding the role of NSSI in emotional

regulation but little was to be found on the actual role NSSI played in the relief (or perception of

relief) of emotional pain (Osuch et al., 2014) (Kirtley, O'Carroll, & O'Connor, The role of

endogenous opioids in non-suicidal self-injurious behavior: Methodological challenges, 2014).

In fact, was it possible to translate this regulation to the management of emotional pain

(Franklin, 2014)? The literature was lacking a common diagnostic framework, one used the term

“regulation” (Nock, Prinstein, Joiner Jr, Lloyd-Richardson, & Gordon, 2006) and another

referred to the same general term as “relief” (Osuch, et al., 2014). Selby, Nock and Kranzler

noted that chronic self-harmers used the phrase “to feel” when describing reasons for the

behavior (2013, p. 418).


Methodology posed a significant problem, there were ethical

considerations regarding allowing or encouraging a person to harm themselves for study.

Another shortcoming was that the sample sizes of the population being studied has been

distressingly small, one of the largest contained 30 participants (Selby, Nock & Kranzler, 2014).

One reason might have been budgetary considering the needed equipment to properly trace the

workings of the brain, such as MRI and PET scans. Kirtley et al supported the need to understand

the “affective regulation” of NSSI outside its association with borderline personality disorder

(The role of endogenous opioids in non-suicidal self-injurious behavior: Methodological

challenges, 2014, p. 186). Reitz et al. agreed that “NSSI remains linked to borderline personality

disorder in the attitude of researchers” (Reitz, et al., 2015, p. 170). Reitz and her co-authors were

the only true study that was found to have used actual incisions to replicate self- harm. The

sample size was 21 women who currently engaged in NSSI and 17 control patients. The

incisions were “acceptable [to] several ethics committees” The participants were given brain

scans to determine the effects of the incision (Reitz, et al., 2015). Kirtley, O’Carroll and

O’Connor continued the discussion on pain and its relationship to self-harm in further research

positing there was an “altered physical pain threshold” but agree that the findings to date were

inconclusive (Pain and self-harm: A systematic review, 2016).

The connection between emotions and pain has been shown and similar areas of the brain

are involved (Athey & Overholser, 2016) (Williams, 2007). With their perspectives combined,

this research implied that the person who self-harmed was attempting to harness the endogenous

opioid process to alleviate emotional pain. Osuch and others used ice to simulate self-harm and

used fMRI scans to determine which area of the brain was involved in the behavior (2014). The

most interesting thing about this study however was that any relief reported was consistent with


self-administered cold “harm” rather than experimenter administered (Osuch, et al., 2014). This

evidence supported the hypothesis that any benefit perceived was due at least in part to self-

administration. This study was similarly limited in scope, with only 13 study participants and 15

control (subjects who had never self-harmed).

There was a distinct disconnect in the language used to describe and analyze NSSI, even

the name of the behavior had many different monikers; cutting, self-harm, self-injury etc. This

issue lacked a structured diagnostic framework necessary to replicate research and provide an

integrated methodology for study. An important first step in this process would be to categorize

the “benefit” that NSSI provides, as this research proposes. To determine whether those who

engage in NSSI actually report emotional pain relief, this research proposes to ask the question

directly of a number of sufferers with effort made to recruit as many participants as possible. It

is predicted that persons who self-harm will correlate the act with a decrease in emotional pain.


Method

Participants

Participants will be truly random, there will be a link to an online survey provided

in various locations using online message boards. Sample bias will be controlled for by posting

the access in as many different places as feasible, up to 200 websites were used. Considering the

broad scope of this proposed method, it will be useful to utilize a few demographic questions to

ensure that we have commiserate numbers of gender, age and ethnicity. The only true sampling

criteria for this research will be that the participants have engaged in self-harm within the last

year. Participants are being asked detailed emotional questions regarding the behavior so the

results will be more accurate if they can remember it clearly. The only expected exclusions are

those who failed to complete the survey.

Material

A simple questionnaire will be used to establish the relationship between self-

reported pain relief and NSSI. Such questions will include: Refer to the Comparative Pain Scale

document and rate your emotional pain from 1-10 before the last time you self-harmed. The

participants will be asked to rate their level of emotional distress using a provided pain scale

before and after self-harm. There will be other questions on the survey such as age, biological

sex, gender and psychiatric diagnoses. To provide an operational definition of the intended

measurement of emotional pain, a scale utilizing levels has been adapted for reference by the

participant.

Procedure

The first page of the online survey will be an informed consent section. Since the

questionnaires will be entirely anonymous a section has been included clearly stating that


continuing to take the assessment constitutes consent. To mask the intention of the study it will

not be specified that emotional pain relief is an area of interest, the consent form states only that

NSSI is being studied. This information will be entered into SPSS to determine the correlation if

any between reported emotional pain relief and self-harm. An adapted form of the Lucile

Packard Children’s Hospital pain scale will be utilized for its simplicity and ease of coding the

responses. This will also allow the participant to make a more accurate scale of pain

measurement. The self-reported pain level from 1-10 will be used for the dependent variable, the

time of report will be both before and after self-harm as the independent variable. The other

information gathered can be added to the dataset to allow for other correlations and relationships

to be studied. The survey questions must be sorted into different orders to control for any

practice effect.


Results

It is expected that the correlation between the self-harm action and reported emotional

pain levels will be moderate to strong in a negative direction, when the self-harm occurs the

emotional pain is lessened. A Pearson Correlation Coefficient will be used to determine the

relationship and direction of the two variables. The independent variable will be the self-harm

action and the dependent variable will be the self-reported level of emotional pain. For the

purposes of this research the following scale will be used to determine strength of

correlation: .0-.19 – very weak, .20-.39 – weak, .40-.59 – moderate, .60-.79 – strong, and .80-1.0

– very strong. The null hypothesis for this research is that there will be no correlation, the

strength of r would be calculated below 0.19 with alpha set at .05. The hypothesis is that there

will be a strong to very strong correlation between self-harm act and reported levels of emotional

pain.


Discussion

Non-suicidal Self-harm has been a growing issue in the psychological and therapeutic

community (Peterson, 2008). It is expected that there will be a positive correlation with reported

emotional pain management and acts of self-harm. This study would be the first step in proving

the relationship between the opioid processes in the brain and self-harm. This link has been

supported by Kirtley, O’Carroll and O’Connor in their investigations of the pain and the

repetitive nature of NSSI (2014). While it is believed that there is a positive correlation between

these two phenomena, the data is valuable even if the null hypothesis is supported. The

therapeutic community would be closer to understanding the function of NSSI in a scientific way

as Scherrer showed in 2014. Taken together with these studies, the proposed research could

illuminate a path to understand why sufferers engage in NSSI at all much less at the repetitive

rate it has been reported (Osuch, Ford, Wrath, Bartha, & Neufeld, 2014). The proposed study has

the benefit of being entirely anonymous, which will encourage a certain amount of honesty in the

participants. This coupled with little to no incentive for prevarication should create reliable

results.

The issue therein could be some limitation with validity, it will be difficult in an

anonymous environment to determine if the population sample we are studying is representative

of the general population. This limitation however also gave rise to a strength, anonymity in the

self-harm community allowed for more honesty and may remove some fears of stigmatization.

An attempt was made to control for this issue by including demographic information in the

questionnaire. Using this information, the survey responses could be grouped in order to study

specific populations separately. Another control considered in the sampling procedure was the


number of surveys generated, it would be beneficial to gather the largest number possible to

compensate for error in procedure.

Non-suicidal self-injury can be devastating to the sufferer and is indicative of a very

troubling lack of care for one’s own well-being (Nock et al, 2006). The scientific community can

benefit from information regarding the endogenous opioid processes of the brain. The average

person has no context for this behavior and may benefit greatly from a deeper understanding of

the issue. If a link between emotional pain relief and self-harm is supported, it could answer one

of the biggest questions surround the behavior; why do they do it? It could also be the beginning

of a diagnostic framework to better understand a dangerous and emotionally crippling

psychological issue. Results supporting this research hypothesis could allow for an expanded

investigation into the correlation. Cohen reports that the stigma associated with NSSI labels the

sufferers as “[…] manipulative, attention seeking, untrustworthy and uncooperative” (2014, p.

12). If NSSI relieves emotional pain, this information can be used to help sufferers mitigate this

stigma along with creating some new research based on the findings.


References

Athey, A., & Overholser, J. (2016, March 15). Learning from Physical Pain to Help with the

Management of Emotional Pain. Journal of Contemporary Psychotherapy, pp. 119-127.

Cohen, L. (2014). Stepping Out of the Shadows: Non-Suicidal Self-Injury as Its Own Diagnostic

Category. Columbia Social Work Review, 10-20. Retrieved November 5, 20015, from

http://cswr.columbia.edu/wp-content/uploads/2014/04/Cohen-2014.-Stepping-out-of-the-

shadows-Non-suicidal-self-injury-as-its-own-diagnostic-category.pdf

Franklin, J. (2014). How Does Self-Injury Change Feelings? Retrieved November 3, 2015, from

Cornell Research Program on Self-Injury and Recovery:

http://www.selfinjury.bctr.cornell.edu/perch/resources/how-does-self-injury-change-

feelings.pdf

In-Albon, T., Ruf, C., & Schmid, M. (2013). Proposed Diagnostic Criteria for the DSM-5 of

Non-Suicidal Self-Injury in Female Adolescents: Diagnostic and Clinical Correlates.

Psychiatry Journal, 1-12. Retrieved November 4, 2015, from

http://www.hindawi.com/journals/psychiatry/2013/159208/

Kirtley, O. J., O'Carroll, R. E., & O'Connor, R. C. (2014, November 18). The role of endogenous

opioids in non-suicidal self-injurious behavior: Methodological challenges. Neuroscience

and Biobehavioral Reviews, pp. 186-189.


Kirtley, O. J., O'Carroll, R. E., & O'Connor, R. C. (2016, May 28). Pain and self-harm: A

systematic review. Journal of Affective Disorders, pp. 347-363.

Nock, M. K., Prinstein, M. J., Joiner Jr, T. E., Lloyd-Richardson, E., & Gordon, K. H. (2006).

Non-Suicidal Self-Injury Among Adolescents: Diagnostic Correlates and Relation to

Suicide Attempts. Psychiatry Research, 65-72.

Osuch, E., Ford, K., Wrath, A., Bartha, R., & Neufeld, R. (2014, Nat 4). Functional MRI of pain

application in youth who engaged in repetitive non-suicidal self-injury vs. psychiatric

controls. Psychiatry Research: Neuroimaging, 223, pp. 104-112.

Peterson, J., Freedenthal, S., Sheldon, C., & Andersen, R. (2008). Non-Suicidal Self Injury in

Adolescents. Psychiatry, 20-26. Retrieved October 24, 2015

Reitz, S., Kluetsch, R., Niedtfeld, I., Knorz, T., Lis, S., Paret, C., . . . Schmahl, C. (2015,

August). Incision and stress regulation in borderline personality disorder: neurobiological

mechanisms of self-injurious behavior. The British Journal of Psychiatry, 2, pp. 165-172.

doi:10.1192/bjp.bp.114.153379

Scherrer, G. I. (2014). Dissociation of the Opioid Receptor Mechanisms That Control

Mechanical and Heat Pain. Biological Psychology. Cengage Learning.

Selby, E. A., Nock, M. K., & Kranzler, A. (2014, December 4). How does self-injury feel?

Examining automatic positive reinforcement in adolescent self-injurers with experience

sampling. Psychiatry Research, pp. 417-423.

Westlund Schreiner, M., Klimes-Dougan, B., & Begnal, E. D. (2015, September 24).

Conceptualizing the neurobiology of non-suicidal self-injury from the perspective of the


Research Domain Criteria Project. Neuroscience and Biobehavioral Reviews (57), pp.

381-391.

Whitlock, J. L., Powers, J. L., & Eckenrode, J. (2006). The Virtual Cutting Edge: The Internet

and Adolescent Self-Injury. Developmental Psychology, 1-11. doi:10.1037/0012-

1649.42.3.000

Wilkinson, P., & Goodyear, I. (2011, January 11). Non-suicidal self-injury. European Child &

Adolescent Psychiatry, 20, pp. 103-108. doi:10.1007/s00787-010-0156-y

Williams, K. D. (2007, August 25). Ostracism. Annual Review of Psychology, pp. 425-452.


Appendix A

Questionnaire

To access this survey online: https://www.surveymonkey.com/r/DBTG62W

1. Have you self-harmed in the last year?

2. How old were you when you first self-harmed?

3. What is your age?

4. Are you White, Black or African-American, American Indian or Alaskan Native, Asian, Native Hawaiian or another Pacific islander, or some other race?

5. Refer to the Comparative Pain Scale document; Rate your emotional pain on a scale of 0-10 before you last self-harmed.

6. What is your gender?

7. How many hours do you sleep each night?

8. Have you been formally diagnosed with a mental illness?

9. If you attend school please select the response that best describes you:

10. Refer to the Comparative Pain Scale document; Rate your emotional pain on a scale of 0-10 after you last self-harmed.


Appendix C

Comparative Pain Scale

0 None

No pain at all

1 Discomforting

Very light barely noticeable pain, most of the time you never think about the pain.

Does not interfere with most activities. Able to adapt to pain

2 Mild

Minor pain, noticeable discomfort that may or may not distract.

3 Tolerable

Very noticeable pain, but not so strong you can't get used to it. After a time, you don't notice it

anymore.

Moderate

4 Distressing

Strong deep pain. So strong you notice the pain all the time and cannot completely adapt.

Interferes with many activities. Unable to adapt to pain

5 Very Distressing

Strong deep piercing pain. Not only do you notice the pain all the time, you are now preoccupied

with managing it.

6 Intense

Strong, deep, piercing pain so strong it seems to partially dominate your senses, causing you to

have somewhat unclear thoughts.

7 Very Intense


Same as 6 except the pain completely dominates your senses. You think unclearly half the time.

At this point you are effectively disabled.

Unable to engage in normal activities. Sufferer is disabled and unable to function independently.

8 Horrible

Pain so intense you can no longer think clearly at all. Suicide is frequently contemplated and

sometimes tried.

9 Unbearable

Excruciating Pain that is so intense you cannot tolerate and demand relief no matter the risk.

There is no joy in life whatsoever.

10 Unspeakable

Unimaginable Pain so intense it causes unconsciousness.

Adapted from Alice Rich, RN Pain Scale Lucile Packard Children’s Hospital

http://salonpas.us/wp-content/uploads/2012/02/0-10_Pain_Scale1.pdf

352 Research Proposal Final Bickford Williams

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