The association between nonsuicidal self-injury and the emotional disorders: A meta-analytic review
Introduction
The phenomenon of self-injury has received increasing attention over the past several decades (Nock, 2010). An important distinction has been made between suicidal behavior and nonsuicidal self-injury (NSSI), with the latter referring to the direct and deliberate destruction of one's own body tissue without suicidal intent (Nock & Favazza, 2009). NSSI is a maladaptive behavior that can result in heightened negative affect, severe injuries, hospitalization, and even death (Briere and Gil, 1998, Klonsky, 2009). Research has also shown that NSSI is a strong predictor of future suicide attempts (e.g., ⁎Asarnow et al., 2011, Bryan et al., 2014, Klonsky et al., 2013, ⁎Wilkinson et al., 2011), and that among both adults and adolescents who engage in NSSI, the risk of suicidal behavior is higher than their non-self-injuring counterparts (e.g., ⁎Andover and Gibb, 2010, Andover et al., 2012, Brausch and Gutierrez, 2010, Martin et al., 2010).
NSSI can present in a number of forms, some of which include cutting, scratching, and burning the skin, inserting objects under the skin, and hitting oneself. Although cutting is most commonly reported, most individuals utilize multiple methods of NSSI (Klonsky, 2007, Klonsky, 2011, Nock, 2010). Prevalence rates of NSSI vary significantly across studies; for example, estimates of lifetime prevalence have ranged from 13% to 45% of community-based adolescents and adults (Briere and Gil, 1998, Lloyd-Richardson et al., 2007, Plener et al., 2009, Ross and Heath, 2002, Shaffer and Jacobson, 2009, Swannell et al., 2014) and 19% to 60% of clinical samples (Briere and Gil, 1998, Darche, 1990, DiClemente et al., 1991). Among samples of individuals with borderline personality disorder (BPD) specifically, rates have been shown to exceed 50% (e.g., ⁎Dulit et al., 1994, Shearer, 1994). One explanation for such wide variation in prevalence rates is the fact that terms used to capture this behavior are inconsistent across the literature (e.g., self-mutilation, deliberate self-harm, parasuicide). Despite difficulties in comparing prevalence rates across studies, findings generally suggest that NSSI occurs more frequently than a number of widely studied mental disorders, such as anorexia nervosa, panic disorder (PD), obsessive–compulsive disorder (OCD), and BPD (American Psychiatric Association, 2013).
In prior iterations of the Diagnostic and Statistical Manual of Mental Disorders (DSM; e.g., DSM-IV-TR; APA, 2000), “self-mutilating behavior” was included only as one of the nine diagnostic criteria for BPD, which may partially explain the elevated rates of NSSI in BPD-specific samples. However, accumulating findings show that NSSI often presents in the absence of BPD (e.g., Muehlenkamp et al., 2011, Nock et al., 2006, ⁎Selby et al., 2012) and can co-occur with a variety of psychological disorders, including eating disorders, substance use, unipolar and bipolar depression, post-traumatic stress disorder (PTSD), generalized anxiety disorder (GAD), social anxiety disorder (SOC), and OCD (e.g., Briere and Gil, 1998, Claes, Klonsky, Muehlenkamp, Kuppens and Vandereycken, 2010, Evren et al., 2008, ⁎Jacobson et al., 2008, Klonsky et al., 2003, Nock et al., 2006, Zlotnick et al., 1999). In response to growing conceptualizations of NSSI as a transdiagnostic phenomenon, rather than a symptom of a single disorder (e.g., Bentley et al., 2014, ⁎Selby et al., 2012, Wilkinson and Goodyer, 2011), numerous calls have been made for the re-classification of NSSI (e.g., Muehlenkamp, 2005, Shaffer and Jacobson, 2009). These proposals resulted in the inclusion of NSSI disorder as an area in need of further study (Section 3) in the recently published DSM-5 (APA, 2013) and emerging research continues to support classifying NSSI as a distinct clinical syndrome (e.g., Andover, 2014, ⁎Glenn and Klonsky, 2013, ⁎In-Albon et al., 2013, Lengel and Mullins-Sweatt, 2013, ⁎Selby et al., 2012).
Given increasing evidence that NSSI commonly presents with disorders other than BPD, as well as enduring uncertainty about where to place NSSI disorder in the DSM (e.g., McKay & Andover, 2012), a more precise understanding of the relationship between NSSI and the range of psychiatric conditions is needed. The “emotional disorders” are one disorder grouping that may warrant particular attention in this line of research. According to Sauer-Zavala and Barlow (2014), emotional disorders refer to psychopathology characterized by “frequent and intense negative emotions, strong aversive reactions to negative emotions, and efforts to avoid or escape these emotional experiences” (p. 118; Barlow, 1991, Brown and Barlow, 2009). Conditions historically thought to fall under the emotional disorder umbrella include the range of DSM-5 (APA, 2013) depressive and anxiety disorders, and obsessive–compulsive and trauma- and stress-related disorders (Barlow, 2002); however, any disorder determined to fit the aforementioned definitional characteristics through functional analysis may be considered within this group.
This definition of emotional disorders demonstrates clear conceptual overlap with the phenomenon of NSSI. As noted above, emotional disorders are characterized by the frequent experience of negative emotions (e.g., fear, anxiety, sadness), which in turn are maintained and exacerbated by the use of maladaptive avoidant strategies (e.g., Aldao et al., 2010, Barlow et al., 2014, Tull and Roemer, 2007, Weiss et al., 2012). Although a variety of models exist to explain why NSSI occurs, there is consensus that NSSI is most often used to regulate affect, and more specifically, to reduce or escape from aversive affective states, such as anxiety, sadness, or guilt (Chapman et al., 2006, Klonsky, 2007, Nock and Prinstein, 2004, Nock and Prinstein, 2005). Thus, NSSI often serves functions equivalent to the attempts to avoid negative emotional experiences that maintain the emotional disorders. Indeed, the association of avoidant coping strategies characteristic of emotional disorders (e.g., rumination, thought suppression) with engagement in and severity of NSSI is now well-established (e.g., Bentley et al., in press, Borrill et al., 2009, Hilt, Cha and Nolen-Hoeksema, 2008, Howe-Martin et al., 2012, McKay and Andover, 2012, Najmi et al., 2007, Nolen-Hoeksema et al., 2008, Voon et al., 2014).
There is also ample evidence to support the presence of similar higher-order constructs underlying the emotional disorders and NSSI. Neuroticism, or the tendency to experience negative emotions accompanied by a sense of the uncontrollability of these emotional experiences (Barlow et al., 2014, Clark, 2005), has been established as an important trait contributing to the development and maintenance of emotional disorders (e.g., Barlow et al., 2014, Brown, 2007, Brown and Barlow, 2009, Kessler et al., 2011). Emerging findings also suggest that levels of neuroticism distinguish self-injuring from non-self-injuring individuals (e.g., Allrogen et al., 2014, Baetens et al., 2012, Claes, Houben, Vandereycken, Bijttebier and Muehlenkamp, 2010, Claes, Klonsky, Muehlenkamp, Kuppens and Vandereycken, 2010, ⁎Claes et al., 2010, MacLaren and Best, 2010, Mullins-Sweatt et al., 2013). Considering this body of empirical literature, it is no surprise that studies have shown emotional disorders and NSSI to frequently co-occur (e.g., ⁎Jacobson et al., 2008, Klonsky et al., 2003), and that individuals who engage in NSSI exhibit elevated levels of anxiety and depression compared to those who do not (e.g., Andover et al., 2005, Brunner et al., 2013, Kirkcaldy et al., 2007, Prinstein et al., 2010).
Given shared funcionality between NSSI and the avoidant coping strategies that maintain emotional disorders, the purpose of the present review is to examine the magnitude of relationships between these two phenomena. Although other conditions (e.g., somatic symptom disorders, eating disorders, substance use disorders) may fit the definitional guidelines of emotional disorders following idiosyncratic functional analysis, the present study focuses on the prototypic emotional disorders (i.e., mood, anxiety, obsessive–compulsive, trauma and stressor-related disorders) for two reasons. First, these disorders are almost always characterized by the avoidant, maladaptive strategies for coping with strong emotions that both define emotional disorders and evidence functional similarity to NSSI for affect regulation. This is not to say, however, that NSSI only co-occurs with emotional disorders, nor that improving our understanding of NSSI as it presents across “non-emotional” disorders is unimportant. Thus, the second reason is that it was beyond the scope of this review to conduct a meta-analysis of all cross-sectional and longitudinal studies reporting any diagnostic information for self-injuring and non-self-injuring individuals. Despite the limitations associated with focusing on one category of psychopathology, this synthesis of available literature on NSSI and emotional disorders serves as a logical starting point toward advancing our understanding of the relationship between NSSI and all mental disorders, as well as other potentially informative constructs.
Although recent evidence suggests that BPD may be best conceptualized as an emotional disorder (e.g., Sauer-Zavala & Barlow, 2014), we do not extend the current meta-analysis to examining the relationship between this particular diagnosis and NSSI. Given that “self-mutilating behavior” is a diagnostic criterion for BPD, this disorder should inherently evidence a particularly strong relationship with NSSI. Thus, quantifying the association of NSSI with this disorder (and comparing it to other emotional disorders) has the potential to introduce criterion contamination. Although some recent research has addressed this issue by removing self-injurious behavior as a BPD symptom (e.g., Glenn & Klonsky, 2011), the vast majority of studies reporting rates of psychiatric diagnoses among individuals with and without NSSI have not; accordingly, we focus primarily on those emotional disorders in which NSSI is not embedded in the diagnostic criteria. In light of the clear relevance of BPD to research on the diagnostic context of NSSI, as well as high comorbidity between BPD and the anxiety and mood disorders (Grant et al., 2008), however, we utilize several analytic strategies to attend to the potential impact of BPD on our findings.
In sum, increasing empirical attention directed toward the transdiagnostic nature, classification, and functionality of NSSI underscores the importance of understanding the relationship between this phenomenon and psychiatric disorders other than BPD, including the emotional disorders. To our knowledge, a quantitative synthesis of available literature on this particular topic does not yet exist; thus, the purpose of this meta-analytic review is to estimate the magnitude of the associations of engagement in NSSI with a variety of emotional disorders. An equally critical aim is to evaluate the quality of evidence supporting a relationship between NSSI and the emotional disorders, which may identify potential areas for refinement of future empirical investigations.
Section snippets
Method
This review complies with the reporting standard set by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement (PRISMA; Moher, Liberati, Tetzlaff, & Altman, 2009).
Description of included studies
The study selection process for this meta-analytic review is presented in Fig. 1. Our initial searches yielded a total of 5659 unique publications. Based on examining titles and abstracts, 237 articles were identified as eligible for further review, of which 56 met inclusion criteria for the meta-analysis. When two publications employed the same sample, we chose the study that was either a peer reviewed journal article (versus a dissertation) or reported more useable effect sizes. The majority
Discussion
The present meta-analysis was designed to examine the relationship between NSSI and a range of emotional disorders (i.e., psychopathology characterized by frequent and intense negative emotions, as well as strong aversive reactions and efforts to escape or avoid such emotions; Barlow, 1991, Sauer-Zavala and Barlow, 2014). Our findings are generally consistent with the increasing literature on the transdiagnostic nature of NSSI, particularly among disorders containing strong emotional components
Conclusions
Despite these limitations, this meta-analytic review had numerous strengths, such as a comprehensive, systematic literature search, a strict definition of NSSI, safeguards to protect against bias (e.g., requiring inter-reviewer agreement), and attention to quality of included studies. Overall, our findings contribute incremental quantitative support to existing theoretical literature suggesting that NSSI is a transdiagnostic phenomenon, and specifically, that it occurs across a range of
Role of funding sources
There was no financial support provided for the conduct of this study.
Contributors
Ms. Bentley designed the study. Ms. Bentley, Ms. Cassiello-Robbins, and Ms. Vittorio conducted the literature search and coded relevant studies. All authors assisted in drafting and have approved the manuscript.
Conflict of interest
The authors have no conflicts of interest to disclose for the present manuscript.
Acknowledgments
The authors would like to thank Margaret S. Andover, Ph.D., Hayley Chartrand, B.A., Veronique C. Jaquier Erard, Ph.D., Sarah E. Gollust, Ph.D., John D. Guerry, Ph.D., Larkin S. McReynolds, Ph.D., Mitchell J. Prinstein, Ph.D., Kaisa Riala, M.D., Ph.D., and Tami P. Sullivan, Ph.D. for providing additional information about their studies included in the meta-analysis.
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