Open Access

Digital comparison of healthy young adults and borderline patients engaged in non-suicidal self-injury

  • Rachel Stroehmer1,
  • Marc A. Edel2,
  • Steffi Pott2,
  • Georg Juckel1, 2 and
  • Ida S. Haussleiter1, 2Email author
Annals of General Psychiatry201514:47

https://doi.org/10.1186/s12991-015-0088-5

Received: 23 June 2015

Accepted: 8 December 2015

Published: 21 December 2015

Abstract

Background

It still remains unclear whether non-suicidal self-injury (NSSI) in young adult populations represents an actual symptom leading to psychiatric illness, constitutes a disorder itself or is rather a cultural peer influence. The purpose of this web-based qualitative cross-sectional study was to characterize NSSI (type of injury, frequency, tools, body parts, circumstances) in 50 patients with borderline personality disorder (NSSI + BPD) in direct comparison with 50 age and gender matched non-clinical young adults (NSSI − BPD), all of them currently or previously engaged in NSSI.

Methods

Self-harming participants completed an open-access, anonymous 75-items questionnaire including the temperament questionnaire briefTEMPS-M.

Results

The mean age of NSSI onset was 20.56 ± 6.36 (NSSI + BPD) and 17.5 ± 9.28 years (NSSI − BPD), respectively (p = 0.261). NSSI − BPD participants (1) rarely sought out medical treatment (p < 0.001) and differed significantly from BPD patients; They (2) reported more often fear and disappointment as feelings preceding their self-harm (p < 0.001 each); (3) cut themselves in more locations (p = 0.005) and (4) in rather hidden areas (lower limb, proximal) (p = 0.002); (5) had lower depressive temperament scores (p = 0.007); and (6) scored generally fewer character traits “at risk” (p = 0.043) with a lower total score (p = 0.018). NSSI tended to onset slightly earlier in life and in different shape when BPD was absent.

Conclusions

Our findings support current approaches of early NSSI recognition and identification of risk profiles. Further prospective studies, which have to be sufficiently large and longitudinal, are needed and of great importance.

Keywords

BriefTEMPS-M Anonymous online questionnaire Hidden body area Borderline personality disorder

Background

Non-suicidal self-injury (NSSI) is defined as “deliberate, self-inflicted destruction of body tissue without suicidal intent and for purposes not socially sanctioned” [1]. NSSI in young adult populations might be an underestimated public health issue and causes significant familial, medical and psychiatric concern [2]. It remains uncertain whether this behavior pattern represents an actual symptom pointing to psychiatric illness, constitutes a disorder in itself or has to be considered a reflection of peer culture influence [3].

The prevalence of self-injury in young adults, including the nonclinical population, may be increasing [4]. One out of three self-injurers reports an onset of self-injurious behavior in childhood, with a peak incidence in mid- to late-adolescence. In most studies, self-cutting is the most common form of self-injury, followed by burning and self-hitting or banging; common locations are the forearms, wrists, and thighs [5]. Klonsky [6] reported that many individuals who engage in NSSI practice more than one of the methods mentioned above. Moreover, lifetime frequency and variety of methods can be taken as indicators of NSSI severity [7]. So far, only few of the young adults affected are seeking medical attention [8].

Over the past few years, several quantitative studies evaluated NSSI in schools [911] and reported inconsistent prevalence between 3 and 37 % [12] for children and adolescents in Germany.

According to DSM-V, borderline personality disorder (BPD) is manifested by a pervasive pattern of instability of interpersonal relationships, self-image and affects, and a marked impulsivity beginning in early adulthood, and occurring in a variety of contexts. NSSI as self-mutilating behavior is considered primarily a function of high BPD symptoms and one of the diagnostic BPD criteria [13, 14]. As NSSI is often present in individuals who are not diagnosed with BPD, the former was considered a distinct category in DSM-V. The precise definition of NSSI might lead to a better comparability of study outcomes with regard to NSSI by a more standardized research [15, 16].

Variables such as emotional dysregulation [17], low social support [18, 19], global psychological distress [8], cognitive style [20], sense of meaning in life [21] and mental health history [5] seem to amplify NSSI and may also mediate the relationship between NSSI and future suicidal thoughts and behaviors [4].

Discussing and reflecting on emotional problems generally seem relieving, but whom one chooses to confide in about such mental distress matters. Talking to peers may actually exacerbate such distress for young people [22], whereas communication with parents is considered a protective factor for later suicidal behavior [4].

So far, there is little evidence on the relationship between BPD symptoms and the functions of NSSI in youth [23]. The purpose of this web-based cross-sectional study was to characterize NSSI in a clinical sample of adult BPD outpatients engaged in NSSI (NSSI + BPD) in comparison with an age- and gender-matched non-clinical sample of adults also endorsed in NSSI (NSSI − BPD). It was hypothesized that these two groups differ in self-harm characteristics (type of injury, frequency, tools, body parts, circumstances) and display different underlying temperament traits (anxious, cyclothymic, depressive, hyperthymic and irritable trait). Focusing on a non-clinical sample may help identify individuals at risk at an early stage, increase awareness, and enable better treatment.

Methods

Participants

We evaluated a clinical and non-clinical sample of young adults, either currently or previously engaged in NSSI. Current NSSI was defined as still on-going at the time of this study. The clinical sample (NSSI + BPD) consisted of 50 unrelated German outpatients (82 % female, mean age 26.8 ± 6.53 years) diagnosed with a BPD according to DSM-IV criteria (301.83) and currently enrolled in outpatient psychiatric treatment in the LWL-University-Hospital Bochum, Germany. The Ethics Committee of the Medical Faculty of the Ruhr-University Bochum approved the study, and written informed consent was obtained from all participants. The non-clinical sample (NSSI − BPD) was matched for age (mean age 26.84 ± 6.23), sex, and ethnicity, and recruited within a larger web-based NSSI survey (data unpublished). This survey exclusively comprised young adults who currently or previously endorsed in NSSI and were not diagnosed with BPD.

Measures

BPD diagnosis was confirmed by the complete Structured Clinical Interview for DSM-IV [24] providing moderate to excellent inter-rater agreement for Axis I disorders, and excellent inter-rater agreement for most categorically and dimensionally measured personality disorders [25].

A questionnaire comprising 40 items was prepared to assess personal information, educational background, family structures, attachment style, and the participants’ social network. Nosological items dealt with psychiatric diagnoses, risk behavior, and substance abuse. Intention, methods, and tools of self-injury were queried in detail. All these items were scored using a five-gradation Likert-type response scale.

The second part of the questionnaire with 35 items consisted of the briefTEMPS-M [26], which is the short German version of the TEMPS-A auto-questionnaire [27]. It evaluates depressive, hyperthymic, cyclothymic, irritable and anxious temperaments and affective disorders in a Likert-type response format and with randomized items.

Examples of the questions included are „People tell me I am unable to see the lighter side of things“, „my mood often changes for no reason“, „I go back and forth between feeling overconfident and feeling unsure of myself”, „The way I see things is sometimes vivid, but at other times lifeless”.

Temperament was analyzed with a dimensional score of the respective temperament scale (percentage of agreement). The temperament trait was coded as clinically present if patients agreed to more than 70 % of the items in accordance with Ozgürdal et al. [28]. Thus, each trait was evaluated relatively (exceeding cutoff) and absolutely (total score). The internal consistency (α) for the briefTEMPS-M varies between 0.69 and 0.84 and the test–retest reliability is 0.49–0.72 [26].

Procedure

Within the study period of 4 months, all BPD outpatients currently or previously engaged in NSSI (NSSI + BPD) were personally invited to participate in the study while waiting for their doctor’s appointment. They subsequently received the link to the study webpage to participate anonymously on their computers at home. Inclusion criteria were: NSSI at present or in anamnesis, being 18 years and older, suffering from BPD, and no acute suicidal ideation. For the non-clinical control group, the link to the study webpage was distributed via online social network (facebook ® ) and German bulletin boards. Exclusion criterion was a diagnosis of BPD and participants were asked whether they currently used the mental health system. Online social networks are an anonymous and client-centered tool to directly get in touch with young people. Nowadays, manifold platforms allow users to share information online with people all over the world such as Twitter®, facebook® and Google+®. The world’s largest social network today is facebook® with 1.44 billion monthly active users as of March 2015 [29].

After reading and digitally signing a statement of informed consent, participants completed the above-mentioned 75-item-questionnaire. Participation was voluntary and anonymous, and all study subjects were assured that their data would be kept confidential. If participants were not engaged in NSSI (both groups) or had a diagnosis of BPD (NSSI − BPD), the questionnaire ended automatically.

The service-platform LimeService was used to prepare, run and evaluate the web-based survey. Distributed under GNU General Public License and written in PHP, it is a free and open source online survey application based on several databases like MySQL. Results were exported and further edited in Microsoft® Excel and IBM® SPSS® Statistics 21.0.

Continuous data are presented with means (M), the standard deviation (SD), and categorical data with number of subjects and percentage. Temperament was analyzed with a dimensional score of the respective temperament scale (percentage of agreement). For comparison of categorical and continuous variables, Chi square tests, t tests or Fisher’s exact test were used where appropriate. A p value of less than 0.05 was interpreted as significant.

Results

Study population

82 % of the participants were female, and the mean age was 26.8 ± 6.53 (NSSI + BPD) and 26.84 ± 6.23 years (NSSI − BPD), respectively (range 18–43 years; p = 0.975). The general qualification for university entrance differed significantly between NSSI + BPD (38 %) and NSSI − BPD (62 %) (p = 0.016), as well as final graduation from university with 4 (NSSI + BPD) and 22 % (NSSI − BPD) (p = 0.015).

NSSI

In both groups, there were more than half of the subjects currently engaged in NSSI (64 NSSI + BPD, 56 % NSSI − BPD; p = 0.414), the remaining subjects reported to have injured themselves in the past, and meanwhile ceased this habit completely. To cease the behavior once and for all, NSSI − BPD participants declared significantly more often relationships as a reason (p = 0.049). Relationships in this context were defined as having a new partner, the ending of a harmful relationship, as well as birth or the growing up of own children. The mean age of NSSI onset was 20.56 ± 6.36 (NSSI + BPD, range 8–33 years) and 17.5 ± 9.28 years (NSSI − BPD, range 6–43 years), respectively (p = 0.261). The claim of mental health services differed significantly between groups: 38 % of the NSSI − BPD group (for other reasons than NSSI) and all NSSI + BPD patients (recruited from a psychiatric outpatient center) underwent treatment (p < 0.001). On a trend level, NSSI + BPD patients (40 %) talked more often with other persons than therapists about their self-injuries than NSSI − BPD subjects (22 %, p = 0.052). Strain, inner emptiness, aggression, and sadness recurrently occurred in both groups prior to each NSSI session. Fatigue (p = 0.006), disappointment, and fear (p < 0.001 each) occurred significantly more often in the control group (NSSI − BPD). The desire to experience oneself more intensely was the main reason to start NSSI in both groups (94 NSSI + BPD, 76 % NSSI − BPD; p = 0.051) and only a minority declared attention-seeking behavior (2 NSSI + BPD, 6 % NSSI − BPD; p = 0.548). Experiencing oneself more intensely was defined as gaining back the sense for one’s own body and replenishing one’s inner emptiness (see Table 1). NSSI + BPD subjects (1.96 ± 1.195) cut themselves in significantly fewer areas than the NSSI − BPD subjects (2.38 ± 1.861; p = 0.005). NSSI + BPD patients cut themselves significantly more often on the upper limbs (p = 0.017), whereas NSSI − BPD subjects significantly more often chose their lower limbs (p = 0.042) (see Fig. 1). NSSI − BPD subjects indicated to cut themselves significantly more often in places not showing when fully clothed such as proximal lower limbs (p = 0.002), whereas NSSI + BPD patients significantly more often chose more visible locations such as distal upper limbs including hands (p = 0.010).
Table 1

NSSI characteristics

 

NSSI + BPD

NSSI − BPD

Chi-squarea /t testb

df

p value

Basics

 Still lasting/current (n, %)

32 (64 %)

28 (56 %)

0.667a

1

0.414

 Age of onset (mean ± SD)

20.56 ± 6.36

17.5 ± 9.28

−1.507b

58

0.137

 Duration (mean ± SD)

  In months, current

66.27 ± 87.61

105.8 ± 84.55

1.774b

58

0.081

  In months, ceased

57.09 ± 77.49

59.58 ± 43.44

0.136b

44

0.892

  Each time in minutes

20.04 ± 25.3

16.34 ± 15.8

−0.878b

98

0.382

 Use of mental health services (n, %)

50 (100 %)

19 (38 %)

44.928a

1

<0.001***

 Talking about NSSI with (n, %)

  Other than therapist

17 (34 %)

10 (20 %)

2.486a

2

0.088

  Parents

3 (6 %)

1 (2 %)

3.835a

2

0.147

 Open presentation (n, %)

8 (16 %)

5 (10 %)

0.796a

1

0.554

 Reason for NSSI (n, %)

  More attention

1 (2 %)

3 (6 %)

1.203a

2

0.548

  Intense feeling

47 (94 %)

38 (76 %)

5.943a

2

0.051

Reason for interruption (each time) (n, %)

 Feelings changed

41 (82 %)

42 (84 %)

0.071a

1

0.790

 Bleeding

20 (40 %)

14 (28 %)

1.604a

1

0.205

 Exhausted

8 (16 %)

15 (30 %)

2.767a

1

0.096

 Caught

8 (16 %)

8 (16 %)

0.000a

1

1.000

Reason for complete discontinuation (n, %)

 Relationship

1 (4.5 %)

7 (29.2 %)

4.901a

2

0.049*

 Therapy

8 (36.4 %)

4 (16 %)

2.903a

2

0.234

 Need

1 (4.5 %)

14 (56 %)

14.561a

2

0.001**

Feelings prior to action (n, %)

 Strain

42 (84 %)

37 (74 %)

1.507a

1

0.220

 Inner emptiness

37 (74 %)

30 (60 %)

2.216a

1

0.137

 Aggression

37 (74 %)

29 (58 %)

2.852a

1

0.091

 Sadness

31 (62 %)

34 (68 %)

0.396a

1

0.529

 Fear

3 (6 %)

25 (50 %)

24.008a

1

<0.001***

 Fatigue

3 (6 %)

14 (28 %)

8.575a

1

0.006**

 Pleasure

1 (2 %)

1 (2 %)

0.000a

1

1.000

 Disappointment

1 (2 %)

22 (44 %)

24.901a

1

<0.001***

Methods

 Number of methods (mean ± SD)

1.78 ± 0.93

1.56 ± 0.91

−1.196b

98

0.235

 Cutting (n, %)

43 (86 %)

40 (80 %)

0.638a

1

0.424

 Hitting (n, %)

24 (48 %)

20 (40 %)

0.649a

1

0.420

 Burning (n, %)

15 (30 %)

16 (32 %)

0.047a

1

0.829

 Trichotillomania (n, %)

7 (14 %)

2 (4 %)

3.053a

1

0.160

Self-cutting localizations

n = 43

n = 40

   

 Number of localizations (mean ± SD)

1.96 ± 1.195

2.38 ± 1.861

1.343b

98

0.005**

 Upper limb (n, %)

43 (100 %)

35 (87.5 %)

4.487a

2

0.017*

  Arm, proximal

17 (39.5 %)

18 (45 %)

0.044a

2

0.834

  Arm, distal

37 (86 %)

32 (80 %)

1.177a

2

0.555

  Arm, distal incl. hand

42 (97.7 %)

32 (80 %)

5.198a

2

0.023*

  Hand (n, %)

16 (37.2 %)

19 (47.5 %)

2.257a

2

0.323

 Lower limb

23 (53.5 %)

30 (75 %)

8.019a

2

0.042*

  Leg, proximal

13 (30.2 %)

26 (65 %)

7.104a

2

0.008**

  Leg, distal

13 (30.2 %)

17 (42.5 %)

3.673a

2

0.159

  Leg, distal incl. foot

14 (32.6 %)

18 (45 %)

0.735a

2

0.391

  Foot

2 (4.7 %)

7 (17.5 %)

5.760a

2

0.056

NSSI + BPD n = 50; NSSI−BPD n = 50; *p < 0.05; **p < 0.01; ***p < 0.001

a Chi-square; b t test

Fig. 1

Preferred localizations of self-cutting in NSSI + BPD (n = 43) and NSSI − BPD (n = 40) subjects

Temperament (character traits) and risk behavior

Table 2 shows the results of the briefTEMPS-M and risk behavior in both groups. The mean number of traits exceeding cutoff was 1.52 ± 1.165 (NSSI + BPD) versus 1.02 ± 1.270 (NSSI − BPD; p = 0.043), the total score was 75.64 ± 19.01 (NSSI + BPD; range 38–119) versus 66 ± 21.17 (NSSI − BPD; range 29–113), respectively (p = 0.018). All but the depressive trait were equally distributed in both groups. All NSSI + BPD patients (100 %) and one-third of NSSI − BPD subjects exceeded the 70 % cutoff of depressive items (p = 0.041). NSSI + BPD patients had a higher total score for all five temperaments and groups differed significantly regarding the depressive trait (p = 0.007). Out of five possible risk behaviors, the study participants on average performed 2.36 ± 1.59 (NSSI + BPD) and 2.36 ± 1.84 (NSSI − BPD; p = 1.000) different ones. Regarding each high-risk behavior in detail, driving at high speed (56 %), staying in obviously dangerous places (44 %), and consuming substances with unknown effects (40 %) occurred more often in the control group, whereas NSSI + BPD patients more often drank too much alcohol (54 %), took drugs (30 %), changed sexual partners more frequently (24 %), and admitted more often to have unprotected sex (20 %).
Table 2

Brief TEMPS-M and risk behavior

 

NSSI + BPD

NSSI − BPD

Chi-squarea /t testb

df

p value

Temperament (mean ± SD)

 Number of traits exceeding cutoff

1.52 ± 1.165

1.02 ± 1.270

−2.052b

98

0.043*

 Total score of traits

75.6 ± 19.01

66 ± 21.17

−2.396b

98

0.018*

 Depressive trait

  Existent (n, %)

25 (50 %)

15 (30 %)

4.167a

1

0.041*

  score (mean ± SD)

19.4 ± 6.2

15.9 ± 6.2

−2.772b

98

0.007**

 Cyclothymic trait

  Existent (n, %)

21 (42 %)

15 (30 %)

1.563a

1

0.211

  Score (mean ± SD)

17.8 ± 5.26

15.48 ± 7.59

−1.776b

98

0.079

 Hyperthymic trait

  Existent (n, %)

3 (6 %)

2 (4 %)

0.211a

1

1.000

  Score (mean ± SD)

9.8 ± 6.55

9.74 ± 4.69

−0.053b

98

0.958

 Irritable trait

  Existent (n, %)

12 (24 %)

10 (20 %)

0.233a

1

0.629

  Score (mean ± SD)

13.9 ± 6.33

11.18 ± 7.97

−1.889b

98

0.062

 Anxious trait

  Existent (n, %)

15 (30 %)

9 (18 %)

1.974a

1

0.160

  Score (mean ± SD)

14.78 ± 6.58

13.68 ± 6.21

−0.860b

98

0.392

Risk behavior

 Number of risk behaviors (mean ± SD)

2.36 ± 1.59

2.36 ± 1.84

0.000b

98

1.000

 Minimum 3 risk behaviors (n, %)

22 (44 %)

19 (38 %)

0.372a

1

0.542

 Drinking too much alcohol (n, %)

27 (54 %)

24 (48 %)

0.360a

1

0.548

 Severity of alcohol use (mean ± SD)c

0.98 ± 1.22

0.98 ± 1.29

0.000b

98

1.000

 Taking drugs (n, %)

15 (30 %)

13 (26 %)

0.198a

1

0.656

 Drug use, severity (mean ± SD)c

0.52 ± 0.93

0.50 ± 0.91

−0.109b

98

0.914

 Driving at high speed (n, %)

22 (44 %)

28 (56 %)

1.440a

1

0.230

 Speed, severity (mean ± SD)c

0.94 ± 1.25

1.34 ± 1.45

1.476b

98

0.143

 Staying in obviously dangerous places (n, %)

15 (30 %)

22 (44 %)

2.102a

1

0.147

 Places, severity (mean ± SD)c

0.52 ± 0.95

0.78 ± 1.15

1.232b

98

0.221

 Substances with unknown effects (n, %)

17 (34 %)

20 (40 %)

0.386a

1

0.534

 Substances, severity (mean ± SD)c

0.66 ± 1.12

1.02 ± 1.42

1.408b

98

0.162

 Changing sexual partners frequently (n, %)

12 (24 %)

7 (14 %)

1.624a

1

0.202

 Having unprotected sex frequently (n, %)

10 (20 %)

4 (8 %)

2.990a

1

0.148

NSSI + BPD n = 50; NSSI − BPD n = 50; *p < 0.05; **p < 0.01; ***p < 0.001

a Chi-square; b t test; c Severity: 0–4

Discussion

The main findings of this cross-sectional study were that control participants (1) rarely sought out medical treatment and in comparison to NSSI + BPD patients; (2) reported more often fear and disappointment as feelings preceding their self-harm; (3) cut themselves in more locations; (4) cut themselves in rather hidden areas (lower limb, proximal); (5) had lower depressive temperament scores; and (6) scored generally fewer briefTEMPS-M character traits “at risk” with a lower total score. Owing to the survey’s anonymity based on an automatic generation of aliases, a high level of openness was possible and expected.

The mean age at the time of the interview was 26.8 years. The average age of onset of NSSI among young adolescents is 12–14 years [30], even though NSSI affects individuals from all age groups [31]. Young adults aged between 18 and 25 years are believed to be at the greatest risk for engaging in such behavior [32]. The indicated age of NSSI onset in our study was 20.56 ± 6.36 and 17.5 ± 9.28 years for NSSI + BPD and control participants (NSSI − BPD), respectively. Even though the groups did not differ significantly in age of NSSI onset, the control participants apparently started earlier with their self-harm behavior. This is all the more interesting, since they sought out professional help for other reasons than their NSSI.

In 2005, Whitlock and colleagues conducted the first large survey-based study of self-injury in a population of 3.069 students. Using a web-based survey, the team examined self-reports of self-injurious practices, age of onset, forms, severity, intention, and help-seeking behavior. One main outcome, consistent with our study, was that NSSI happened in individuals who had never been in therapy for any reason, and that only few of them disclosed their behavior and sought help [8]. The study at hand confirms the communication difficulties of self-injurers, since only 12 % of the control participants talked about their behavior whereas almost half of them (44 %) performed self-harm without confiding in anyone.

Even though NSSI can occur in the course of psychiatric disorders, recent studies suggest that the social circumstances and experiences of the person concerned are more crucial in explaining what leads to self-harm than a diagnosed psychiatric disorder [33]. NSSI might be a particular reaction to emotional distress and not necessarily herald a manifest disease. On the other hand, the assumption that patients endorsing NSSI are more attention seeking and manipulative and less in genuine need of mental health might lead to an underestimation of the severity and potential lethality of NSSI [30, 34].

People engaged in NSSI often report greater emotional dysregulation than those without NSSI history and NSSI has been associated with an emotion regulation function and trait emotion dysregulation among people who self-injure [35]. We accordingly discovered that strain, inner emptiness, aggression and fear led to participants’ self-injuries.

To our knowledge, no empirical studies investigating in detail the body locations chosen for self-injury have yet been conducted. In our study, NSSI − BPD subjects chose more different locations, which were at the same time easily hidden and concealed from the detection of others, whereas NSSI + BPD subjects deliberately cut themselves in more exposed regions.

A number of risk factors for self-injury have been identified including depressed mood, increased anxiety, low self-esteem and cognitions that focus upon self-failure [36, 37]. Depression and anxiety in adolescence are associated with an increased incidence of self-harm in young adulthood [38] but generally measured current depressive or anxiety traits lacked discriminative ability in distinguishing between history of and ongoing NSSI in our study.

NSSI + BPD subjects might suffer from axis I disorders more frequently than the NSSI − BPD controls. Turner et al. (2015) observed that BPD patients showed greater diagnostic comorbidity, particularly for anxiety disorders, but did not differ from participants without BPD in rates of mood, substance or psychotic disorders. The NSSI + BPD group in that study reported more severe depressive symptomatology, suicidal ideation and emotion dysregulation than the NSSI − BPD group [39]. An effect of such possible comorbidities on our outcome parameter (NSSI characteristics) is possible but seems less significant. There is no clinical explanation as to why an existing psychiatric comorbidity should, for example, alter the localization pattern of self-cutting. Regarding temperament traits and risky behaviors, the two groups in the current study did not differ significantly. NSSI + BPD patients generally scored higher—in terms of total briefTEMPS-M score—than control participants (NSSI − BPD) and groups differed highly significant only in depressive temperament (p = 0.007). Highest score possible for one trait was 28 (7 questions with 4 severity grades each). Therefore, the mean total scores can be similar, since the scores of all participants are included in the calculation. For the calculation of clinically present temperament traits on the other side, only those with a score greater or equal to 20 points (70 % cutoff) were included. Thus, the discrepancy can be explained by the fact that more NSSI + BPD patients scored 20 and higher (exceeding cutoff), whereas more NSSI − BPD subjects scored in the double-digit range (adding up to a relatively higher total score in this group).

Cyclothymic, irritable and especially depressive temperaments might represent an important marker of vulnerability to NSSI in young adults [40] and the higher rate of dominant affective temperaments found among NSSI + BPD patients might reflect the suggested relationship between affective temperaments and full-blown mood disorders [41, 42], which are often comorbid to BPD [43].

The present study has certain limitations that need to be taken into account when interpreting its results: The size of the subgroups was relatively small with 50 participants each, limiting the representativeness and reliability of the data and also precluding meaningful subgroup analysis. The advantage of an anonymous online survey allowed for more openness and a higher rate of participation when talking about such a delicate and potential embarrassing topic such as NSSI.

Manifest BPD has to be absent in NSSI − BPD group, but due to the design of the study (using an anonymous online questionnaire) a further clinical interview was not feasible. Surely, when anonymized, honesty has to be assumed. If participants indicated a BPD diagnosis, the questionnaire ended automatically. Overall, we registered 516 accesses to the webpage, whereof 328 questionnaires were complete. The complete sample of controls, out of which the group in the current study was drawn (matching the BPD patients in age and gender), comprised over 300 non-clinical young adults. Based on the total population of more than 300 young adults, it seems highly unlikely that all of our matched controls “secretly” suffered from a BPD and did not report it.

The questionnaire to qualitatively assess NSSI and accompanying factors has been developed for this pilot study and not been validated or standardized beforehand. Available standardized NSSI instruments were either not in an appropriate format for the purpose of this study (open-ended question inquiring about methods used for NSSI in the Self-Harm Behavior Questionnaire by Fliege et al. [44]) or did not exist yet in a translated and validated German version (such as the self-injurious thoughts and behaviors interview by Fischer et al. [45]).

Nevertheless, the study benefits from examining a wide range of NSSI characteristics, including method type, number of methods, location, reasons for discontinuation, age at onset, duration of engagement, reasons for engagement, feelings experienced before engagement which would not have been possible with a pre-built questionnaire.

Both samples were heterogeneous in terms of the types of self-injurious behaviors they were engaged in (e.g., substance use, abusive relationships, and risky behavior). People who engage in some of these behaviors may be different from those who engage in others.

In conclusion, our findings support current approaches of early NSSI recognition and identification of risk profiles. Further prospective studies are needed and of great importance. They have to be sufficiently large and longitudinal to directly focus on the limitations named above.

Ethics, consent, and permissions

The Ethics Committee of the Medical Faculty of the Ruhr-University Bochum approved of the study, and written informed consent was obtained from all participants. The study has, therefore, been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments.

Declarations

Authors’ contributions

RS conceived the study, and participated in its design and coordination, performed the statistical analysis and helped to draft the manuscript; this study is part of her academic thesis. MAE participated in the design and interpretation of the data; SP participated in the coordination of the study and performed the measurement; GJ participated in the design and coordination of the study and interpretation of the data; ISH conceived the study, participated in its design and coordination and drafted the manuscript. All the authors read and approved the final manuscript.

Acknowledgements

We thank S. Koessler for language revision of the manuscript.

Competing interests

G. Juckel has been advisor to Pfizer, Astra Zeneca and BMS. He received grand support from Pfizer, Lilly, Janssen and Astra Zeneca and speaker’s honoraria from Janssen, Pfizer, BMS and Astra Zeneca. All authors declare that they have no competing interests.

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Authors’ Affiliations

(1)
LWL-Institute of Mental Health, LWL-University Hospital Bochum
(2)
Dept. of Psychiatry, LWL-University Hospital Bochum

References

  1. International Society for the Study of Self-injury (ISSS). Definitional issues surrounding our understanding of self-injury. Conference proceedings from the annual meeting. 2007.Google Scholar
  2. Kaminski JW, Puddy RW, Hall DM, Cashman SY, Crosby AE, Ortega LA. The relative influence of different domains of social connectedness on self-directed violence in adolescence. J Youth Adolesc. 2010;39:460–73.PubMedView ArticleGoogle Scholar
  3. Brunner R, Schmahl C. Nicht-suizidales selbstverletzendes Verhalten bei Jugendlichen und jungen Erwachsenen (non-suicidal self-injury in adolescents and young adults). Kindheit und Entwicklung. 2012;21:5–15.View ArticleGoogle Scholar
  4. Whitlock J, Muehlenkamp JJ, Purington A, Eckenrode J, Barreira P, Baral Abrams G, Marchell T, Kress V, Girard K, Chin C, Knox K. Non-suicidal self-injury in a college population: general trends and sex differences. J Am Coll Health. 2011;59:691–8.PubMedView ArticleGoogle Scholar
  5. Jacobson CM, Muehlenkamp JJ, Miller AL, Turner JB. Psychiatric impairment among adolescents engaging in different types of deliberate self-harm. J Clin Child Adolesc Psychol. 2008;37:363–75.PubMedView ArticleGoogle Scholar
  6. Klonsky ED. The functions of deliberate self-injury: a review of the evidence. Clin Psychol Rev. 2007;27:226–39.PubMedView ArticleGoogle Scholar
  7. Miranda R, De Jaegere E, Restifo K, Shaffer D. Longitudinal follow-up study of adolescents who report a suicide attempt: aspects of suicidal behavior that increase risk of a future attempt. Depress Anxiety. 2014;31:19–26.PubMedView ArticleGoogle Scholar
  8. Whitlock J, Eckenrode J, Silverman D. Self-injurious behaviors in a college population. Pediatrics. 2006;117:1939–48.PubMedView ArticleGoogle Scholar
  9. Brunner R, Parzer P, Haffner J, Steen R, Roos J, Klett M, Resch F. Prevalence and psychological correlates of occasional and repetitive deliberate self-harm in adolescents. Arch Pediatr Adolesc Med. 2007;161:641–9.PubMedView ArticleGoogle Scholar
  10. Resch F, Parzer P, Brunner R, BELLA study group. Self-mutilation and suicidal behaviour in children and adolescents: prevalence and psychosocial correlates: Results of the BELLA study. Eur Child Adolesc Psychiatry. 2008;17:92–8.PubMedView ArticleGoogle Scholar
  11. Plener PL, Libal G, Keller F, Fegert JM, Muehlenkamp JJ. An international comparison of adolescent non-suicidal self-injury (NSSI) and suicide attempts: Germany and the USA. Psychol Med. 2009;39:1549–58.PubMedView ArticleGoogle Scholar
  12. Plener PL, Brunner R, Resch F, Fegert JM, Libal G. Nonsuicidal self-injury in adolescence. Z Kinder Jugendpsychiatr Psychother. 2010;38:77–89.PubMedView ArticleGoogle Scholar
  13. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. USA: Arlington; 2013.View ArticleGoogle Scholar
  14. Selby EA, Bender TW, Gordon KH, Nock MK, Joiner TE Jr. Non-suicidal self-injury (NSSI) disorder: a preliminary study. Personal Disord. 2012;3:167–75.PubMedView ArticleGoogle Scholar
  15. Shaffer D, Jacobson C. Proposal to the DSM-V childhood disorder and mood disorder work groups to include non-suicidal self-injury (NSSI) as a DSM-V disorder. Washington: American Psychiatric Association; 2009.Google Scholar
  16. Plener PL, Kapusta ND, Brunner R, Kaess M. Non-suicidal self-injury (NSSI) and suicidal behavior disorder (SBD) in the DSM-5. Z Kinder Jugendpsychiatr Psychother. 2014;42:405–11.PubMedView ArticleGoogle Scholar
  17. Nock MK, Mendes WB. Physiological arousal, distress tolerance, and social problem-solving deficits among adolescent self-injurers. J Consult Clin Psychol. 2008;76:28–38.PubMedView ArticleGoogle Scholar
  18. Whitlock J, Knox KL. The relationship between suicide and self-injury in a young adult population. Arch Pediatr Adolesc Med. 2007;161:634–40.PubMedView ArticleGoogle Scholar
  19. Wilkinson P, Kelvin R, Roberts C, Dubicka B, Goodyer I. Clinical and psychosocial predictors of suicide attempts and non-suicidal self-injury in the adolescent depression antidepressants and psychotherapy trial (ADAPT). Am J Psychiatry. 2011;168:495–501.PubMedView ArticleGoogle Scholar
  20. Claes L, Houben A, Vandereycken W, Bijttebier P, Muehlenkamp JJ. Brief report: the association between non-suicidal self-injury, self-concept and acquaintance with self-injurious peers in a sample of adolescents. J Adolesc. 2010;33:775–8.PubMedView ArticleGoogle Scholar
  21. Muehlenkamp JJ, Gutierrez PM. Risk for suicide attempts among adolescents who engage in non-suicidal self-injury. Arch Suicide Res. 2007;11:69–82.PubMedView ArticleGoogle Scholar
  22. Hankin BL, Stone LB, Wright PA. Co-rumination, interpersonal stress generation, and internalizing symptoms: accumulating effects and transactional influences in a multiwave study of adolescents. Dev Psychopathol. 2010;22:217–35.PubMedPubMed CentralView ArticleGoogle Scholar
  23. Sadeh N, Londahl-Shaller EA, Piatigorsky A, Fordwood S, Stuart BK, McNiel DE, Klonsky ED, Ozer EM, Yaeger AM. Functions of non-suicidal self-injury in adolescents and young adults with borderline personality disorder symptoms. Psychiatry Res. 2014;216:217–22.PubMedView ArticleGoogle Scholar
  24. Fydrich T, Renneberg B, Schmitz B, Wittchen HU. SKID-II. Interviewheft. Strukturiertes Klinisches Interview für DSM-IV. Achse II: Persönlichkeitsstörungen [SCID-II. Structured Clinical Interview für DSM-IV. Axis II: Personality disorders]. Göttingen: Hogrefe; 1997.Google Scholar
  25. Lobbestael J, Leurgans M, Arntz A. Inter-rater reliability of the structured clinical interview for DSM-IV Axis I disorders (SCID I) and Axis II disorders (SCID II). Clin Psychol Psychother. 2011;18:75–9.PubMedView ArticleGoogle Scholar
  26. Erfurth A, Gerlach AL, Hellweg I, Boenigk I, Michael N, Akiskal HS. Studies on a German (Muenster) version of the temperament auto-questionnaire TEMPS-A: construction and validation of the briefTEMPS-M. J Affect Disord. 2005;85:53–69.PubMedView ArticleGoogle Scholar
  27. Akiskal HS, Mendlowicz MV, Jean-Louis G, Rapaport MH, Kelsoe JR, Gillin JC, Smith TL. TEMPS-A: validation of a short version of a self-rated instrument designed to measure variations in temperament. J Affect Disord. 2005;85:45–52.PubMedView ArticleGoogle Scholar
  28. Ozgürdal S, van Haren E, Hauser M, Ströhle A, Bauer M, Assion HJ, Juckel G. Early mood swings as symptoms of the bipolar prodrome: preliminary results of a retrospective analysis. Psychopathology. 2009;42:337–42.PubMedView ArticleGoogle Scholar
  29. facebook® newsroom. http://newsroom.fb.com/company-info/. Accessed 31 May 2015.
  30. De Leo D, Heller TS. Who are the kids who self-harm? an Australian self-report school survey. Med J Aust. 2004;181:140–4.PubMedGoogle Scholar
  31. Lengel GJ, Mullins-Sweatt SN. Nonsuicidal self-injury disorder: clinician and expert ratings. Psychiatry Res. 2013;210:940–4.PubMedView ArticleGoogle Scholar
  32. Rodham K, Hawton K. Epidemiology and phenomenology of non-suicidal self-injury. In: Nock MK, editor. Understanding nonsuicidal self-injury. Washington: American Psychological Association; 2009. p. 9–18.Google Scholar
  33. Straiton M, Roen K, Dieserud G, Hjelmeland H. Pushing the boundaries: understanding self-harm in a non-clinical population. Arch Psychiatr Nurs. 2013;27:78–83.PubMedView ArticleGoogle Scholar
  34. Andrews T, Martin G, Hasking P, Page A. Predictors of continuation and cessation of non-suicidal self-injury. J Adolesc Health. 2013;53:40–6.PubMedView ArticleGoogle Scholar
  35. Andover MS, Morris BW. Expanding and clarifying the role of emotion regulation in non-suicidal self-injury. Can J Psychiatry. 2014;59:569–75.PubMedPubMed CentralGoogle Scholar
  36. St Germain SA, Hooley JM. Direct and indirect forms of non-suicidal self-injury: evidence for a distinction. Psychiatry Res. 2012;197:78–84.PubMedView ArticleGoogle Scholar
  37. McAuliffe C, Corcoran P, Keeley HS, Arensman E, Bille-Brahe U, De Leo D, Fekete S, Hawton K, Hjelmeland H, Kelleher M, Kerkhof AJ, Lönnqvist J, Michel K, Salander-Renberg E, Schmidtke A, Van Heeringen K, Wasserman D. Problem-solving ability and repetition of deliberate self-harm: a multicentre study. Psychol Med. 2006;36:45–55.PubMedView ArticleGoogle Scholar
  38. Moran P, Coffey C, Romaniuk H, Olsson C, Borschmann R, Carlin JB, Patton GC. The natural history of self-harm from adolescence to young adulthood: a population-based cohort study. Lancet. 2012;379:236–43.PubMedView ArticleGoogle Scholar
  39. Turner BJ, Dixon-Gordon KL, Austin SB, Rodriguez MA, Zachary Rosenthal M, Chapman AL. Non-suicidal self-injury with and without borderline personality disorder: differences in self-injury and diagnostic comorbidity. Psychiatry Res. 2015;230:28–35.PubMedView ArticleGoogle Scholar
  40. Guerreiro DF, Sampaio D, Rihmer Z, Gonda X, Figueira ML. Affective temperaments and self-harm in adolescents: a cross-sectional study from a community sample. J Affect Disord. 2013;151:891–8.PubMedView ArticleGoogle Scholar
  41. Van Meter AR, Youngstrom EA. A tale of two diatheses: temperament, BIS, and BAS as risk factors for mood disorder. J Affect Disord. 2015;180:170–8.PubMedView ArticleGoogle Scholar
  42. Zeschel E, Bingmann T, Bechdolf A, Krüger-Oezguerdal S, Correll CU, Leopold K, Pfennig A, Bauer M, Juckel G. Temperament and prodromal symptoms prior to first manic/hypomanic episodes: results from a pilot study. J Affect Disord. 2015;173:39–44.PubMedView ArticleGoogle Scholar
  43. Lieb K, Zanarini MC, Schmahl C, Linehan MM, Bohus M. Borderline personality disorder. Lancet. 2004;364:453–61.PubMedView ArticleGoogle Scholar
  44. Fliege H, Kocalevent RD, Walter OB, Beck S, Gratz KL, Gutierrez PM, Klapp BF. Three assessment tools for deliberate self-harm and suicide behavior: evaluation and psychopathological correlates. J Psychosom Res. 2006;61:113–21.PubMedView ArticleGoogle Scholar
  45. Fischer G, Ameis N, Parzer P, Plener PL, Groschwitz R, Vonderlin E, Kölch M, Brunner R, Kaess M. The German version of the self-injurious thoughts and behaviors interview (SITBI-G): a tool to assess non-suicidal self-injury and suicidal behavior disorder. BMC Psychiatry. 2014;14:265.PubMedPubMed CentralView ArticleGoogle Scholar

Copyright

© Stroehmer et al. 2015

Advertisement