Nonsuicidal Self-Injury Disorder: An Empirical Investigation in Adolescent Psychiatric Patients

Abstract

Nonsuicidal self-injury (NSSI) is a growing public health concern, especially among adolescents. In the current edition of the Diagnostic and Statistical Manual of Mental Disorders, NSSI is classified as a criterion of borderline personality disorder (BPD). However, a distinct NSSI disorder will now be included in DSM–5 as a “condition requiring further study.” It is important to note that, at this time, there is little direct evidence supporting the DSM–5 proposal over the DSM–IV classification. To address this need, the current study examined the extent to which NSSI occurs independently of BPD and has clinical significance beyond a diagnosis of BPD in adolescent psychiatric patients. NSSI disorder was assessed based on the proposed DSM–5 criteria in 198 adolescents ages 12 to 18 (74% female; 64% Caucasian, 14% Hispanic, 10% African American, and 12% mixed/other ethnicity) from a psychiatric hospital. Major Axis I disorders, Axis II BPD, and suicide ideation and attempts were assessed with structured clinical interviews; emotion dysregulation and loneliness were measured with validated self-report questionnaires. First, results indicated that NSSI disorder occurred independently of BPD. Specifically, although there was overlap between the occurrence of BPD and NSSI disorder, this overlap was no greater than that between BPD and other Axis I disorders (e.g., anxiety and mood disorders). Second, NSSI disorder demonstrated unique associations with clinical impairment—indexed by suicide ideation and attempts, emotion dysregulation, and loneliness—over and above a BPD diagnosis. Taken together, findings support the classification of NSSI as a distinct and clinically significant diagnostic entity.

Acknowledgments

This project was supported in part by an NIH grant (MH08009601) awarded to E. David Klonsky, Ph.D. Special thanks to Kristie Golden, Ph.D., as well as to the staff and patients at South Oaks Hospital—The Long Island Home for all their support with this project.

Notes

¹Some may argue that a BPD diagnosis should serve as a rule-out for NSSI and that it should not be possible to diagnose both BPD and NSSI. Unfortunately, because the DSM–5 Personality Disorders workgroup was never asked to reconsider the role of NSSI in the BPD criteria, the future role of NSSI as a criterion for BPD is unclear. What we do know is that the current version of the proposed NSSI disorder criteria do not include BPD as a rule-out, and thus allow for the possibility of comorbid NSSI disorder and BPD.

²There were no differences between the sub threshold NSSI disorder and noninjuring clinical comparison groups in age (p = .321), ethnicity (ps > .48 for all group comparisons), emotion dysregulation (all ps > .26), loneliness (p = .792), suicide ideation or attempts (all ps > .65), rates of all major Axis I disorders (all ps > .19), or rates of BPD (p = .132). However, there were more female adolescents in the sub threshold NSSI group (76%) than in the noninjuring comparison group (54%), χ²(1, N = 100) = 5.05, p = .025.

Note: DERS = Difficulties in Emotion Regulation Scale.

^a n = 98.

^b n = 100.

^c Dimensional group differences were examined using independent-samples t tests and Cohen's d for effect size. Categorical group differences were examined using Pearson chi-square tests and Cramer's phi coefficients (Φ) for effect size.

^d Grade refers to the last grade of school completed.

^e Alcohol/Substance use disorder includes presence of current alcohol abuse/dependence or substance abuse/dependence. Anxiety disorder includes presence of any of the following current disorders: panic disorder, agoraphobia, social phobia, specific phobia, obsessive-compulsive disorder, posttraumatic stress disorder, or generalized anxiety disorder. ADHD/Disruptive behavior disorder includes presence of current attention-deficit hyperactivity disorder, conduct disorder or oppositional defiant disorder. Mood disorder includes presence of current bipolar I, bipolar II, major depressive disorder, or dysthymia. Total Number of Disorders is count score of the Axis I disorders listed above (scores range 0–13).

³The Benjamini–Hochberg procedure (Benjamini & Hochberg, 1995) was used to control the false discovery rate for multiple comparisons. Using this procedure, it was determined that all results reported as significant at p < .05 in Tables 2, 4, and 5 were not likely to be due to Type I error.

Note: Alcohol/Substance use disorder includes presence of current alcohol abuse/dependence or substance abuse/dependence. Anxiety disorder includes presence of any of the following current disorders: panic disorder, agoraphobia, social phobia, specific phobia, obsessive-compulsive disorder, posttraumatic stress disorder, or generalized anxiety disorder. ADHD/Disruptive behavior disorder includes presence of current attention-deficit hyperactivity disorder (ADHD), conduct disorder or oppositional defiant disorder. Mood disorder includes presence of current bipolar I, bipolar II, major depressive disorder, or dysthymia. NSSI = nonsuicidal self-injury.

⁴The patterns of results for all NSSI disorder clinical impairment analyses were the same (a) when the suicide/self-injury criterion was excluded from the BPD diagnostic variable, and (b) when a continuous BPD symptom variable was used (instead of the dichotomous diagnostic variable).

Note: UCLA = University of California Los Angeles.

*p < .05. **p < .01. ***p < .001.