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Article Excerpt
This study examines characteristics (i.e., prevalence, method, age of onset, frequency) of nonsuicidal self-injury (NSSI) and associated risk factors in a college student sample. Results revealed 11.68% admitted to engaging in NSSI at least once and no significant gender difference in occurrence of NSSI. Even in this college sample, those who self-injure differed substantially from non-self-injurers with regard to emotion regulation, but were not found to differ significantly on either early attachment or childhood trauma and abuse. Importance of understanding NSSI as an emerging behavior among college students is discussed.
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The occurrence of nonsuicidal self-injury (NSSI) amongst college students has increasingly come to the attention of the mental health professionals (Whitlock, Purington, Eells, & Cummings, 2006). In a recent survey of school counselors' experiences with NSSI, the major concern expressed was a lack of training in this area and the need to be informed about the occurrence and characteristics of NSSI (Heath, Toste, & Beettam, 2007). The present paper provides information on the basic facts and associated risk factors of NSSI in college students.
Defining the exact parameters of NSSI behavior has not been straightforward and interpreting the research in the field can be challenging due to differences in the operationalization of the definition. In response to these concerns, the International Network for the Study of Self-injury (ISSS) was established in 2006 by leading researchers in the field of self-injury to work towards a consensus regarding key issues. One year later, in June 2007, the ISSS agreed on the following definition of NSSI:
The deliberate, self-inflicted destruction of body tissue resulting in immediate damage, without suicidal intent and for purposes not socially sanctioned. As such, this behavior is distinguished from: suicidal behaviors involving an intent to die, drug overdoses, and other forms of self-injurious behaviors, including culturally-sanctioned behaviors performed for display or aesthetic purposes; repetitive, stereotypical forms found among individuals with developmental disorders and cognitive disabilities, and severe forms (e.g., self-immolation and auto-castration) found among individuals with psychosis. (ISSS, 2007)
However, NSSI can be understood as a subset of the larger range of self-harming behaviors. Deliberate self-harm, as defined by the Child and Adolescent Self-harm (CASE) group in Europe, is an act with a nonfatal outcome in which an individual deliberately does one or more of the following: initiated behavior (e.g., self-cutting, jumping from a height) intended to cause self-harm; ingested a substance in excess of the prescribed or generally recognized therapeutic dose; ingested a recreational or illicit drug that was an act that the person regarded as self-harm; or ingested a non-ingestible substance or object, irrespective of suicidal intent (Hawton, Rodham, Evans, & Weatherall, 2002; Hawton et al., 2003). More recently, Hawton and colleagues have sought to change the term from deliberate self-harm to self-harm (Hawton & James, 2005).
Clearly, self-harm is a broader construct than NSSI and critical readers of the literature should be aware that NSSI, while subsumed under the self-harm definition, cannot be equated with other self-harming behaviors. In their classification of suicide-related behaviors, Silverman et al. (2007) categorize each behavior on the basis of suicidal intent (e.g., none, undetermined, some) and outcome (e.g., fatal injury, non-fatal injury, no injury). Silverman and colleagues emphasize the importance of determining the suicidal intent or motivation behind the behavior. Thus, while in the past deliberate self-harm as studied in Europe has largely not evaluated suicidal intent, Silverman et al. insist that in the future, behaviors that differ in suicidal intent cannot be equated. In summary, while NSSI may be related to other suicidal behaviors, it is a distinct and separate behavior from either suicide attempts or the broader deliberate self-harm definition. When one reviews the literature, or is attempting to identify NSSI in a clinical setting, it is essential to distinguish between the range of self-harm behaviors that may have suicidal intent and NSSI, which does not.
Many assertions have been made about the increase of "self-injury" in youth and young adults (e.g., Adler & Adler, 2007; Favazza, 1998) and this behavior has been referred to as the new youth epidemic or the "new" anorexia (Shaw, 2002; Zila & Kiselica, 2001). However, the empirical evidence documenting an increase in self-injury has been limited to studies of the broader construct of deliberate self-harm (e.g., Hawton, Fagg, Simkin, Bale, & Bond, 2000; Hawton et al., 2003). Although no empirical research presents results directly demonstrating an increase, Whitlock et al. (2006) found that counselors in a college setting reported that an increased number of clients were coming forward with NSSI. Similarly, Heath, Toste, and Beettam (2006) found that high school teachers perceived NSSI behavior to be on the rise. Thus, although it appears that NSSI is increasing, this could be a result of students becoming more willing to disclose the behavior and seek support. In the following section, a brief review of studies examining the prevalence of NSSI in youth and young adults will be presented and research examining the risk factors for NSSI in community samples will be discussed.
Prevalence of Self-Injury in the Community
Researchers have investigated the prevalence of NSSI in community samples of both adolescents and young adults. In general, lifetime prevalence rates for adolescents and young adults in the community range between 10% to 20% (e.g., Muehlenkamp & Gutierrez, 2007; Ross & Heath, 2002; Whitlock, Eckenrode, & Silverman, 2006). Where notably discrepant results are found (e.g., Gratz, 2006; Lloyd-Richardson, Perrine, Dierker, & Kelley, 2007) with much higher prevalence rates, checklists of all possible self-injurious behaviors were presented to the participants and they were asked to indicate every behavior in which they had engaged. This method consistently results in higher incidence reporting. By providing a list of many possible forms of tissue damage (e.g., biting, sticking pins in skin, scraping skin, interfering with wound healing), the definition is effectively broadened as many participants would not think to identify themselves as a "self-injurer" on the basis of interference with wound healing, one of the listed behaviors. In addition, participants' understanding of the behavior may not be consistent with the researchers' conceptualization. For example, "sticking pins into skin" may be a NSSI behavior or it may be related to drug use, self-tattooing, or other body modifications. Ideally, with a checklist, a follow-up interview should be conducted to clarify the occurrence and intent of the behavior.
Another notable finding in reviewing the literature on prevalence of NSSI is that there is more likely to be a gender difference when examining clinical samples than community samples (e.g., Jacobsen, Muehlenkamp, & Miller, 2006; Nixon, Cloutier, & Aggarwal, 2002). This may be because women are more prone to seek help than men, or due to the inclusion of overdose or inappropriate ingestion of medication without suicidal intent in many of the studies conducted in clinical settings, which have been found to be largely female behaviors (e.g., Briere & Gil, 1998; Rodham, Hawton, & Evans, 2004). In examining the prevalence of NSSI for male and female participants within community samples, it appears that the inclusion of overdose and ingestion of substances may be at the root of the observed gender differences. Specifically, studies of self-injury in community samples that have revealed gender differences (e.g., Laye-Gindhu & Schonert-Reichl, 2005; Nixon, Cloutier, & Jansson, 2007; Patton et al., 1997) have included overdose or abuse of pills/medication without suicide intent. Studies that have limited their definition to behaviors such as cutting, burning, self-hitting, and other forms of direct tissue damage have failed to find gender differences (e.g., Izutsu et al., 2006; Lloyd-Richardson et al., 2007; Muehlenkamp & Gutierrez, 2004; 2007; Ross & Heath, 2002; Zoroglu et al., 2003). This pattern holds true in studies exploring NSSI among young adults; with the exception of Whitlock, Eckenrode, and Silverman (2006), who reported a very small gender difference. Thus, NSSI may not necessarily be a predominately female behavior, although in clinical samples there are significantly...
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