Non-suicidal self-injury in adolescents: Forms, functions and

clinical implicationsMarc Wilson, Jessica Garisch, Robyn Langlands, Angelique O’Connell, Lynne Russell,

Emma-Jayne Brown & Tahlia Kingi

NZCCP Conference, Christchurch, April 2014

Youth Wellbeing Study

• Longitudinal survey with secondary school students.

• Non-Suicidal Self-injury

• Primarily investigating– Risk and protective factors for the development of non-suicidal self-

injury

– Barriers to help-seeking

Trajectory of NSSI among young New Zealanders

• We have data spanning age-groups

– 13 – 15 years olds

– 16 – 19 year olds

– University students (M=19 yo)

How do these groups compare in prevalence, form and function of NSSI…

Prevalence

• YWS Wave 1 results– N=1027 (991 responded to questions on NSSI)

• 213 (21%) engaged in NSSI at least once– 81.6% had engaged in NSSI in the past year

• Senior secondary school students– N=1162

• 48.7% had engaged in NSSI at least once– 53.6% had engaged in NSSI in past year

» 46.4% over a year ago

• University students– N= 593

• 43.7% had engaged in NSSI at least once

YWS wave 1: Further information on prevalence...

Type of NSSI Neverthought about

Thought about, never done

Have done once

Have done a few times

Have done many times

Cut 80.2 6.0 3.8 6.2 3.8

Scratched 87.5 2.7 3.8 4.0 1.9

Carved 89.2 2.3 3.7 3.0 1.7

Punched/ banged

90.3 2.5 3.7 2.7 0.7

Stuck sharp objects

91.1 2.1 3.4 2.4 0.9

Prevent healing 91.8 1.5 3.3 1.9 1.4

Bitten self 93.8 2.4 2.4 1.0 0.4

Burn 94.3 2.7 1.5 1.0 0.5

Rubbed glass 96.0 1.4 1.5 0.8 0.3

Broken bones 97.1 1.6 0.7 0.4 0.2

Rubbed sandpaper

97.7 1.1 0.8 0.3 0.1

Dripped acid 99.2 0.3 0.2 0.0 0.0

Used bleach/ cleaning agent

99.2 0.7 0.1 0.0 0.0

Prevalence of Types of NSSI

• YWS Wave 1 sample

– Cutting most common

– Severe scratching, carving the skin, punching or banging

• Senior Secondary School students

– Sticking sharp objects into the skin, carved, scratch most common

– Cutting

Other types assessed (e.g. using acid, sandpaper, etc.) much less frequently reported.

Types of NSSI generally cluster into 2 factors: ‘common’ + ‘uncommon’

Engagement in multiple types of NSSI

University student data suggests that the majority of young people engage in 1 – 3 types of NSSI...

Engagement in multiple types of NSSI

• YWS Wave 1

• Of the 213 who reported NSSI– 25.6% reported 1 form

– 17.4% reported 2 forms

– 15.5% reported 3 forms

– 37.1% reported > 3 forms

Self-reported Function of NSSI

• Three datasets investigating functions

– Senior Secondary school data

– Adult data

– Wave 1 YWS

Functions: Senior secondary school students

• Functional Assessment of Self-Mutilations (FASM; Lloyd et al., 1997)

• Identified three factors:– Intrapersonal (endorsed by 38.2% participants)

• “To feel more a part of a group”

• “To get your parents to understand or notice you”

– Emotional relief/control (endorsed by 18.2%)

• “To feel something, even if it is pain”

• “To punish yourself”

– Avoidance (endorsed by 20.0%)

• “To avoid being with people”

• “To avoid punishment or paying the consequences”

Adult Community Sample (Langlands, 2012)Using the Inventory of Statement about Self-Injury (ISAS) (Klonsky & Olino, 2008)

Inte

rper

son

alIn

trap

erso

nal

YWS Wave 1: Four Clusters(Functions assessed using FASM (Klonsky & Olino, 2008)

Interpersonal:

Other-focused

Interpersonal: self-focused

Intrapersonal: Disconnection

Intrapersonal: Affect & Punish

Functions & Psycho-social functioning

• Generally, intrapersonal functions (both disconnection and affect regulation/self-punishment) most strongly associated with indicators of poor functioning...

Anxiety

Leve

l of

Fun

ctio

n e

nd

ors

emen

t

DepressionLe

vel o

f Fu

nct

ion

en

do

rsem

ent

Attachment to Parents

Leve

l of

Fun

ctio

n e

nd

ors

emen

t

Attachment to PeersLe

vel o

f Fu

nct

ion

en

do

rsem

ent

Emotion Regulation

Leve

l of

Fun

ctio

n e

nd

ors

emen

t

ResilienceLe

vel o

f Fu

nct

ion

en

do

rsem

ent

Suicidal Ideation

Leve

l of

Fun

ctio

n e

nd

ors

emen

t

Self-EsteemLe

vel o

f Fu

nct

ion

en

do

rsem

ent

YWS: Participant Clusters by Function

• Cluster 1: Affect regulation & self-punishment (n=75)

• Cluster 2: Low on all (n=81)

• Cluster 3: Highest on intrapersonal (n=13)

• Cluster 4: High on all, highest on both interpersonal (n=22)

0

1

2

C1

C4

C2

C3

• Klonsky & Olino (2008)

YWS: Clusters + Psycho-social functioning

• Four clusters differed significantly on:– Suicidality (notably C1 and C3)

– Self-esteem

– Resilience

– Depression

– Anxiety

– Emotion regulation

– Attachment to parents (but not peers...)

– NSSI behaviour

Cluster 2 (low on all) generally the best

The NUMBER of types of self-injury engaged in is strongly predictive of suicidal ideation:

For each additional form, SBQ scores increase:

1 form SBQ = 3.5ish

2 forms SBQ = 5ish

3 forms SBQ = 7ish

7 is the recommended cutoff for concern…

0

1

2

0

1

2

3

4

5

6

C1 C2 C3 C4N

um

be

r o

f o

rms

of

NSS

I e

nga

ged

in

YWS: Participant Clusters by NSSI forms

C1

C4

C2

C3

0

1

2

YWS: Participant Clusters by NSSI forms

C1 – 2nd most likely to cut, 3rd most likely for most forms

C4 – most likely to self-bite, 2nd most likely for most.Most likely to have thought about ‘atypical’ self-injury like bone breaking, using glass, bleach, etc

C2

C3 – Most likely to cut, carve, insert

Implications for clinical practice

• Results congruent with the idea that NSSI begins in early adolescents, and continues into early adulthood for some individuals

• Forms of NSSI: multiple behaviours need to be queried.

• Functions

– Heterogeneity

– Affect regulation most prevalent

Implications for clinical practice continued...

• Functions can point to skills required...

– Affect regulation• Distress tolerance skills

• Labelling and communicating emotions

• Understanding beliefs regarding experiencing (and showing) emotion

Acknowledgements

• Participating schools + students

• HRC

Thanks for listening

Any questions? Comments?