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A cross-sectional study of adolescent non-suicidal self-injury: support for a specific distress-function relationship
Linköping University, Department of Clinical and Experimental Medicine, Division of Clinical Sciences. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Local Health Care Services in Central Östergötland, Department of Child and Adolescent Psychiatry in Linköping.
Department of Psychology, Lund University, Sweden.
Linköping University, Department of Clinical and Experimental Medicine, Division of Clinical Sciences. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Local Health Care Services in Central Östergötland, Department of Child and Adolescent Psychiatry in Linköping.
2014 (English)In: Child and Adolescent Psychiatry and Mental Health, ISSN 1753-2000, E-ISSN 1753-2000, Vol. 8, no 23Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: This study has investigated the specific relationship between childhood adversities, individual trauma symptoms and the functions of non-suicidal self-injury (NSSI). The aim was to examine whether different self-reported adverse experiences and trauma symptoms predict the need to engage in NSSI, either to regulate emotions or to communicate with and influence others.

METHOD: The participants were a community sample of 816 adolescents aged 15-17 years with NSSI. Hierarchical multiple regression was used, controlling for NSSI frequency and gender. The dependent variables were the automatic and social functions of NSSI, respectively. The predictors entered in the model were several different maltreatment and adversity experiences as well as individual trauma symptoms. Mediation analyses were also performed using the bootstrapping method with bias-corrected confidence estimates.

RESULTS: Frequency of NSSI, gender (female), emotional abuse, prolonged illness or handicap during upbringing and symptoms of depression uniquely predicted the automatic functions of NSSI in the final regression model, but not the social functions. Symptoms of anxiety uniquely predicted social but not automatic functions. Having experienced physical abuse, having made a suicide attempt and symptoms of dissociation were significant predictors in both final models. The model for automatic functions explained more of the variance (62%) than the social model (28%). The relationship between childhood emotional, physical and sexual abuse and performing NSSI for automatic reasons was mediated by symptoms of depression and dissociation. The relationship between physical abuse and the social functions of NSSI was mediated by symptoms of anxiety and dissociation.

CONCLUSIONS: It is important to understand the specific context in which NSSI has developed and is maintained. Experiences of emotional abuse and symptoms of depression could guide clinical work in the direction of emotion regulation skills since in this study these variables were uniquely associated with the need to engage in NSSI to regulate emotions, to self-punish or to generate feelings. The presence of physical abuse, a suicide attempt and symptoms of dissociation could alert clinicians to a broad treatment approach since they were associated with performing NSSI to regulate both social and automatic experiences.

Place, publisher, year, edition, pages
BioMed Central, 2014. Vol. 8, no 23
National Category
Psychiatry Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
URN: urn:nbn:se:liu:diva-110419DOI: 10.1186/1753-2000-8-23PubMedID: 25110519OAI: oai:DiVA.org:liu-110419DiVA: diva2:745790
Available from: 2014-09-11 Created: 2014-09-11 Last updated: 2017-12-05Bibliographically approved
In thesis
1. Non-Suicidal Self-Injury in Swedish Adolescents: Prevalence, Characteristics, Functions and Associations With Childhood Adversities
Open this publication in new window or tab >>Non-Suicidal Self-Injury in Swedish Adolescents: Prevalence, Characteristics, Functions and Associations With Childhood Adversities
2014 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Non-suicidal self-injury (NSSI), such as intentionally cutting, burning or hitting oneself, is a behavior with potentially detrimental consequences and empirical studies are necessary to gain knowledge of how to prevent NSSI in adolescents. The aims of this thesis were to investigate the prevalence, methods, characteristics and functions of NSSI in a large community sample of Swedish adolescents, and to examine the relationship between NSSI and adverse life events and trauma symptoms. All empirical studies had a cross-sectional design and were based on 3,097 adolescents in the county of Östergötland, aged 15-17 years, in their first year of high school. Participating school classes were selected through a randomization process and administered self-report questionnaires.

In study I (n = 3,060) a single item NSSI question resulted in a prevalence rate of 17.2%, while 35.6% of adolescents reported having engaged in NSSI at least once during the past year when given a checklist. The most commonly reported type of NSSI in this sample was “bit yourself”, followed by “hit yourself on purpose”, “erased your skin” and “cut or carved on your skin”. Applying the proposed DSM-5 diagnostic criteria of NSSI resulted in a prevalence rate of 6.7%. Results in study II (n = 2,964) showed that after controlling for gender, parental occupation and living conditions, adolescents with no self-injurious behavior reported the lowest level of adversities and trauma symptoms, while adolescents with both NSSI and suicide attempts (5.7%) reported the highest levels compared to those with only NSSI or a suicide attempt. Adolescents reporting frequent NSSI reported more adversities and trauma symptoms than those with less frequent NSSI. Automatic functions, such as affect regulation, self-punishment and feeling-generation, were the most commonly reported functions of NSSI. Attempts in study I to confirm Nock and Prinstein’s (2004) four-factor model of underlying factors of NSSI functions resulted in a close to acceptable fit. An attempt to refine the factor analysis on this community sample of Swedish adolescents, using Mplus with cross-validation, was made in study III (n = 836). An exploratory factor analysis resulted in a three-factor model (social influence, automatic functions and non-conformist peer identification), which was validated in confirmatory analysis. In order to adhere more closely to learning theory and the concept of negative and positive reinforcement, the third factor was then split into two factors, resulting in a four-factor model (social influence, automatic functions, peer identification and avoiding demands), which showed excellent fit to the data in the confirmatory factor analysis. Study IV (n = 816) showed that NSSI frequency, gender (female), self-reported experience of emotional and physical abuse, having made a suicide attempt, prolonged illness or handicap and symptoms of depression and dissociation were significant predictors in the final model of the automatic functions, indicating that these variables are important in understanding the mechanisms underlying the need to engage in NSSI to regulate emotions, generate feelings, gain control or to self-punish. Symptoms of depression and dissociation mediated the relationship between sexual, physical and emotional abuse and the automatic  functions. Furthermore, frequency of NSSI, gender, emotional abuse, prolonged illness or handicap and symptoms of depression uniquely predicted automatic functions but not social functions. Self-reported experience of physical abuse, having made a suicide attempt, symptoms of anxiety and dissociation were significant in the final model of social functions, i.e., performing NSSI to influence or  communicate with others, to avoid demands or to identify with peers. Of these, symptoms of anxiety were uniquely associated with social functions. Symptoms of anxiety and dissociation mediated the relationship between physical abuse and social functions of NSSI.

Taken together, this thesis has shown that NSSI is prevalent in Swedish adolescents and findings contribute to the discussion of a potential NSSI diagnosis. It is important to consider the effect of different types of negative life events and trauma symptoms in relation to NSSI in adolescents. Assessing the specific reinforcing functions of NSSI and the underlying factor structure can be helpful in developing functionally relevant individualized treatment.

Abstract [sv]

Självskadebeteende, t ex att avsiktligt skära, bränna eller slå sig själv är potentiellt skadliga beteenden. Empiriska studier är viktiga för att kunna förebygga självskadebeteende hos ungdomar. Föreliggande avhandling syftar till att undersöka självskadebeteendets förekomst, funktion, karaktäristik och metoder hos svenska ungdomar, samt att undersöka relationen till negativa livshändelser och traumasymptom. Samtliga fyra empiriska studier hade en tvärsnittsdesign och baserades på 3,097 ungdomar i Östergötland, 15-17 år, i gymnasieskolans årskurs 1, vars skolklasser valts ut slumpmässigt och som besvarat självskattningsformulär.

I studie I (n = 3,060) angav 17.2%, som svar på en allmän självskadefråga, att de avsiktligt skadat sig under sin livstid. När ungdomarna däremot svarade på en checklista med olika självskadebeteenden, angav 35.6% att de hade ägnat sig åt någon typ av självskadebeteende under det senaste året. De vanligaste metoderna var att avsiktligt bita eller slå sig själv, sudda på huden och att skära sig. De föreslagna diagnoskriterierna för icke-suicidal självskada i DSM-5 resulterade i en förekomst av 6.7%. Studie II (n = 2,964) visade att ungdomar utan självskadebeteende rapporterade de lägsta antalet negativa livshändelser och traumasymptom, medan de med erfarenhet av både självskadebeteende och självmordsförsök (5.7%) rapporterade de högsta antalen jämfört med de med endast självskadebeteende eller självmordsförsök. Ungdomar med fler självskadetillfällen rapporterade fler negativa livshändelser och traumasymptom än de med färre tillfällen. Automatiska/intrapersonella funktioner, såsom att generera och reglera känslor samt att straffa sig själv var de vanligaste funktionerna som rapporterades. Försök att konfirmera Nock och Prinsteins (2004) fyrfaktormodell av underliggande funktionsfaktorer i studie I resulterade i en modell med nära acceptabel passform. Ett försök att förbättra faktoranalysen på den aktuella urvalsgruppen gjordes med Mplus i studie III (n = 836). En exploratorisk analys resulterade i en trefaktormodell (interpersonell påverkan, automatisk/intrapersonell funktion samt ”icke-konformistisk” kamratidentifikation), vilken även validerades i den konfirmatoriska analysen. Med utgångspunkt i inlärningsteori och begreppen negativ och positiv förstärkning delades därefter den tredje faktorn upp i två faktorer. Det resulterade i en fyrfaktormodell (interpersonell påverkan, automatisk/intrapersonell funktion, kamratidentifikation samt undvikande av krav). Fyrfaktormodellen visade utmärkt passform i den konfirmatoriska analysen. Studie IV (n = 816) visade att självskadebeteendets frekvens, kön (flicka), självrapporterade erfarenheter av psykisk och fysisk misshandel, självmordsförsök, kronisk sjukdom eller handikapp under uppväxten, liksom symptom på depression och dissociation predicerade automatiska självskadefunktioner. De variablerna är potentiellt viktiga för förståelsen av de mekanismer som är involverade när ungdomar skadar sig själva för att generera och reglera känslor, få kontroll, liksom att straffa sig själva. Relationen mellan psykisk och fysisk misshandel och de automatiska funktionerna medierades av symptom på depression och dissociation. Självskadefrekvens, kön, psykisk misshandel, sjukdom/handikapp och symptom på depression predicerade enbart automatiska men inte sociala funktioner. Självrapporterad fysisk misshandel, självmordsförsök, symptom på ångest och dissociation var signifikanta prediktorer för de sociala funktionerna (att påverka/kommunicera med andra, undvika krav eller identifiera sig med kamrater). Ångestsymptom var unikt associerade med sociala funktioner. Symptom på ångest och dissociation medierade vidare relationen mellan fysisk misshandel och sociala självskadefunktioner.

Sammanfattningsvis visade resultaten att självskadebeteende är vanligt förekommande hos ungdomar. Avhandlingen bidrar med empiri till diskussionen gällande icke suicidal självskada i DSM-5. Det är viktigt att beakta olika negativa livserfarenheter och traumasymptom i relation till självskadebeteende hos ungdomar. Att undersöka självskadebeteendets funktioner kan vara kliniskt hjälpsamt för att utveckla och utvärdera individuellt anpassade behandlingsstrategier.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2014. 89 p.
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1416
Keyword
Non-suicidal self-injury, adolescents, prevalence, functions, adversities, trauma symptoms
National Category
Clinical Science Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:liu:diva-110421 (URN)10.3384/diss.diva-110421 (DOI)978-91-7519-250-5 (ISBN)
Public defence
2014-10-03, Berzeliussalen, Campus US, Linköpings universitet, Linköping, 09:00 (English)
Opponent
Supervisors
Available from: 2014-09-11 Created: 2014-09-11 Last updated: 2015-01-27Bibliographically approved

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Zetterqvist, MariaSvedin, Carl Göran
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