Abstract
Background
Non-suicidal self-injury (NSSI) is an intentional act that results in physical damage to one’s body, without the intent to commit suicide. In recent years, self-injurious behaviors, including non-suicidal self-injury (NSSI), have increased, especially among adolescents and young adults. The objective of this study was to investigate the motives for NSSI among adolescents with psychiatric disorders.
Methods
Adolescents aged 12 to 18 years including patients admitted to the Department of Child and Adolescent Psychiatry at a state hospital in Babol (northern Iran) and outpatients referring to this center were included in the research. Data collection occurred between February 2021 and September 2021 from a sample of 140 participants. All subjects were given a demographic questionnaire and an inventory of statements about self-injury (Klonsky and Glenn). Moreover, a structured interview was conducted with all to diagnose the nature of the underlying disorder by a child and adolescent psychiatrist.
Results
A total of 140 adolescents with mean age 16.25 ± 1.48 years were assessed. Eighty-five (60.7%) of them were girls. Sixty-five (46.4%) individuals were inpatients and 75 (53.6%) were outpatients; 78 (55.8%) had a history of NSSI and 62 (44.2%) cases had no history of self-injury. The most common method of self-injury was Wounding or cutting a part of the body (n = 56(40.0%)). Attention-deficit/hyperactivity disorder (ADHD) emerged as the most common psychiatric diagnosis among individuals with a history of NSSI. Emotion regulation was the most common motive for self-injury (p = 0.004). The prevalence of self-injury was higher among adolescent girls (p = 0.049). There was no significant relationship between self-injury and inpatient or outpatient status (p = 0.342).
Conclusions
Our findings indicate that NSSI in adolescents is not limited to a specific or single motive; instead, multiple factors contribute to its occurrence. NSSI methods can also vary, and all should be considered when examining this behavior.
Keywords: Self-injurious behavior, Mental disorders, Adolescent
Introduction
Self-injury encompasses a spectrum of behaviors, including direct methods like intentional tissue damage (NSSI) and head banging, and indirect methods like substance abuse and risky activities. These behaviors, regardless of suicidal intent, are considered socially and culturally unacceptable. These behaviors, whether suicidal or not, are socially and culturally unacceptable [1, 2].
In recent years, self-injurious behaviors, including non-suicidal self-injury (NSSI), have increased, especially among adolescents and young adults [3, 4]. Studies conducted to date in the area of self-injury in clinical and nonclinical populations have reported varying prevalence of this behavior. Overall, the prevalence of NSSI in a meta-analysis study was 17.2% among adolescents, 13.4% among young adults, and 5.5% among adults [5]. A cross-sectional study conducted in Brazil reported a 25% prevalence of self-injury among adolescents, with girls seven times more likely to self-injure than boys. The study also highlighted factors such as intent to die, recurrence, age of onset, and health care assistance in relation to self-injury [6]. In a study of the prevalence of self-injury in Iran, it was reported that 17.9% of female students had engaged in self-injury at least once and 11.1% more than once in the past year [4].
Despite the increasing trend of NSSI among adolescents, researchers and mental health professionals have prioritized understanding the underlying factors that lead adolescents to engage in this behavior. Identifying these reasons is crucial for developing effective prevention and treatment strategies. Until we have a clear grasp of the driving forces behind NSSI, a comprehensive understanding of this issue remains elusive. According to international research, the rate of self-injurious thoughts and behaviors increases sharply in the transition to adolescence, and the highest prevalence of suicidal thoughts occurs in mid-adolescence [7]. Therefore, adolescents are more affected by self-injurious behavior than other age groups. Yet these adolescents are the ones who guarantee the future of a society, and their mental and physical health is one of the sources of power in societies. While the Research has shown that NSSI can be a risk factor for future suicidal behavior [8–10]. More than 60% of people who die by suicide have a history of self-injurious behavior [10]. This is despite the fact that we might have been able to prevent the suicide if we had noticed the person’s self-injurious behavior in time and known their motivations such as emotional dysregulation or coping mechanisms. After all, only when we know the full dimension of a behavior and what a person’s motives are for his or her behavior can we take appropriate and effective therapeutic action. limited research has focused on the specific motivations of adolescents with diagnosed psychiatric disorders seeking treatment at hospital centers. This study aims to contribute to this gap by investigating the motives for NSSI in this specific population. So, the aim of this study was to investigate non-suicidal self-injury (NSSI) among adolescents with psychiatric disorders referred to Babol Shahid Yahyanejad Hospital.
Methods
This descriptive cross-sectional study involved adolescents undergoing psychiatric treatment. The study sample included all 12–18-year-old patients, referred to Babol Yahyanejad Hospital from February 2021 to September 2021 who were receiving psychiatric treatment. The present study examined the frequency of NSSI and its motivations in 140 of these patients. Written informed consent was obtained from the parents or legal guardians of participants aged 12-18 years and explained the study procedures, potential risks and benefits, and participants’ rights to withdraw from the study at any time. To determine an appropriate sample size that would provide adequate statistical power for the primary outcome measures, we conducted a power analysis using G*Power 3.1. Based on an effect size of 0.5, a significance level of 0.05, and a power of 0.8, a sample size of 128 participants was determined. However, we recruited a sample of 140 participants to account for potential attrition and to enhance the precision of our estimates.
During the 8-month study period, a total of 140 child and adolescent patients were evaluated, including 65 inpatients and 75 outpatients (between 12 and 18 years old). All inpatients and outpatients met the inclusion criteria and participated in the study. To collect data, all 140 patients were asked to complete a questionnaire. The study procedures and questionnaire completion process were fully explained to the patients before they filled out the questionnaire. After completion, the questionnaires were reviewed again to ensure they were complete and accurate. Consequently, no questionnaires were excluded due to incompleteness.
Inclusion criteria
Inclusion criteria were age 12-18 years, ability to speak and absence of cognitive impairment, full consent of adolescents to complete the questionnaire honestly, Iranian nationality, and willingness to participate in the study.
Exclusion criteria
Exclusion criteria for the study were intellectual disability and autism spectrum disorders that affect the conduct of the interview and the accuracy of the adolescents’ responses. Another criterion for exclusion from the present study was the inability to read and write, which made the adolescent unable to complete the questionnaire, and which was also considered as one of the possible reasons for the adolescents’ cognitive weakness.
Using the sample size formula and following the study by Turner et al. [11], P was equated with the percentage of self-injury by cutting in psychiatric patients. For the error level d = 0.1p, the sample size was set to 131 participants.
Convenience sampling method was used to select the sample population in the present study, which corresponded to the desired subject and research method.
A demographic questionnaire and an inventory of statements about self-injury were administered to the 12-18-year-old patients, referred to the Department of Child and Adolescent Psychiatry at Shahid Yahyanejad Hospital by a psychiatric assistant. For inpatients, the questionnaire was submitted after the acute phase of the illness and at the time of partial recovery (before discharge) so that the responses would not be influenced by the acute phase of the illness and would be more reliable. To diagnose a psychiatric disorder, a semi-structured clinical interview based on the Kiddie Schedule for Affective Disorders and Schizophrenia Present and Life Time Version (K- SADS-PL) was also conducted by a child and adolescent psychiatrist.
Demographic questionnaire
This questionnaire included information on age, gender, and education.
Self-injurious behavior and functioning scale (Klonsky and Glenn, 2015)
This questionnaire consists of two parts: The first list contains a listing of types of self-injurious behavior and the second list contains 39 questions on a Likert scale that captures the motives of self-injury. The second part consists of two factors for intrapersonal and interpersonal functioning (motivations) and measures thirteen types of functioning. The participant was asked to rate the questions on each subscale with a score from 0 to 2, considering the question “When I self-injure…”. The maximum score the participant could achieve on each scale was 6.
In the psychometric study, the two-factor structure (intrapersonal and interpersonal factors) of this scale was extracted from 235 students who had a history of self-injury at least once. The Cronbach’s alpha for the intrapersonal and interpersonal factors was 0.88 and 0.80, respectively. Participants’ scores on this scale were shown to correlate with clinical scales measuring symptoms of borderline personality, suicide, depression, and anxiety [12]. In another study, the test-retest reliability coefficient of this scale within one year was reported to be 0.60 for intrapersonal factors and 0.82 for interpersonal factors [12].
In a study conducted by Khanipour et al. (2016) in Iran, the Cronbach’s alpha coefficient for the total score of this test was 0.94 [13].
The reliability of the questionnaire of the current study was indicated by the Cronbach’s alpha coefficient as 0.700 for self-injurious methods and 0.822 for self-injurious functions, which is “good” and “excellent” respectively.
Semi-structured clinical interview
This interview was conducted by a child and adolescent psychiatrist using K-SADS-PL and was based on the criteria of the Diagnostic and Statistical Guide to Mental Disorders, Fifth Edition of Diagnosis.
Data analysis method
The data collected were analyzed using SPSS version 22. To analyze the data of the ongoing study, indicators such as frequency, percentage, mean and standard deviation were given in the descriptive statistics section. In the inferential part, chi-square, Mann-Whitney test and Kruskal Wallis Test were used to check the desired relationships. A value of p < 0.05 was considered significant.
Results
The number of persons studied was 140 (99 persons with a history of self-injury and 41 cases without such a history). The mean age of all 140 participants in the study and of those who had committed NSSI was 16.25 ± 1.48 and 12.94 ± 2.79 years, respectively. The youngest age of the person studied was 12 years and the oldest age was 18 years. In the present study, 85 (60.7%) of adolescents were girls, 55 (39.3%) were boys, and 99 (70.7%) ones had a history of NSSI. Also, there was no statistically significant difference in gender between people with and without NSSI (P.value = 0.139), but there was a significant difference in admission status between them (P.value ≤ 0.001).
In this study, the most common psychiatric disorder was “attention-deficit/hyperactivity disorder” (ADHD), with a frequency of 34 (24.3%) participants in the total sample (Fig. 1). In addition, co-occurrence of bipolar disorder and ADHD was the most common psychiatric disorder among adolescents with a history of NSSI, with a frequency of 26 (26.3%) individuals. The function of self-injurious behavior without suicidal intent according to gender is given in Table 1. Based on this table, only Anti-dissociative was statistically different between girls and boys (P.value = 0.012). Anti-dissociative was more in girls than boys (1.90 vs. 0.68). Table 2 shows the function of self-injurious behavior without suicidal intent in general and according to the most common psychiatric disorders. Based on this table, a significant statistical difference was observed only in Belonging to peers between the 4 groups of most common psychiatric disorders (P.value = 0.008). Belonging to peers in the group diagnosed with ADHD + BID was higher than the other groups (3.45 ± 7.67).
Fig. 1.
Distribution of psychiatric disorders(number) among the participants [attention deficit hyperactivity disorder (ADHD), Bipolar I Disorder (BID), Oppositional Defiant Disorder (ODD), Major Depressive Disorder (MDD), obsessive compulsive disorder (OCD)]
Table 1.
The function of self-injurious behavior without suicidal intent in according gender
| Function of non-suicidal self-injury behavior | Mean (SD) | |||
|---|---|---|---|---|
| Total | Male | Female | P value* | |
| Emotion Regulation | 3.94(1.91) | 3.30(2.20) | 4.23(1.72) | 0.095 |
| Distinguishing oneself from others | 1.69(1.92) | 1.08(1.41) | 1.97(2.07) | 0.114 |
| Self-punishment | 2.48(1.86) | 2.21(1.88) | 2.59(1.87) | 0.463 |
| Self-care | 1.24(1.69) | 0.73(1.25) | 1.47(1.82) | 0.091 |
| Anti-dissociative | 1.52(1.96) | 0.68(1.21) | 1.90(2.12) | 0.012 |
| Anti-suicide | 1.95(1.80) | 1.54(1.73) | 2.13(1.81) | 0.173 |
| Excitement | 0.79(1.15) | 0.73(1.00) | 0.82(1.22) | 0.911 |
| Belonging to peers | 1.33(4.22) | 1.17(1.80) | 1.41(4.96) | 0.366 |
| Interpersonal influence | 1.52(1.73) | 1.56(1.70) | 1.50(1.76) | 0.785 |
| Demonstration of power | 1.43(1.68) | 1.09(1.63) | 1.58(1.70) | 0.193 |
| Expression of confusion | 2.20(1.73) | 1.63(1.46) | 2.46(1.79) | 0.090 |
| Revenge | 1.24(1.56) | 0.82(1.33) | 1.42(1.63) | 0.118 |
| Autonomy | 1.27(1.61) | 1.13(1.39) | 1.33(1.71) | 0.822 |
*Mann-Whitney test
Table 2.
The function of self-injurious behavior without suicidal intent in general and according to the most common psychiatric disorders
| Function of non-suicidal self-injury behavior | Mean (SD) | ||||
|---|---|---|---|---|---|
| Without the most common psychiatric disordersa | ADHD | BID | ADHD+ BID | P value* | |
| Emotion Regulation | 4.40(1.50) | 4.25(2.17) | 3.52(2.11) | 3.65(1.87) | 0.437 |
| Distinguishing oneself from others | 1.77(1.66) | 1.50(1.82) | 2.00(2.40) | 1.47(1.80) | 0.808 |
| Self-punishment | 3.20(1.64) | 2.25(2.04) | 2.78(2.09) | 1.65(1.42) | 0.051 |
| Self-care | 1.35(1.66) | 1.12(1.66) | 0.88(1.56) | 1.55(1.90) | 0.640 |
| Anti-dissociative | 2.30(2.34) | 0.86(1.50) | 1.27(1.70) | 1.47(1.95) | 0.215 |
| Anti-suicide | 2.65(1.89) | 1.43(1.59) | 1.77(1.73) | 1.85(1.84) | 0.280 |
| Excitement | 0.95(1.14) | 1.00(1.36) | 0.27(0.75) | 0.95(1.23) | 0.122 |
| Belonging to peers | 0.30(0.73) | 0.93(1.52) | 0.50(0.85) | 3.45(7.67) | 0.008 |
| Interpersonal influence | 1.42(1.74) | 1.31(1.49) | 1.38(1.91) | 1.90(1.80) | 0.588 |
| Demonstration of power | 1.75(1.71) | 1.50(1.96) | 0.70(1.21) | 1.68(1.70) | 0.161 |
| Expression of confusion | 2.10(1.48) | 2.06(2.11) | 2.33(1.71) | 2.31(1.76) | 0.879 |
| Revenge | 1.05(1.39) | 0.93(1.38) | 1.57(1.70) | 1.35(1.75) | 0.618 |
| Autonomy | 1.25(1.40) | 1.37(1.78) | 0.94(1.34) | 1.52(1.95) | 0.795 |
*Kruskal Wallis Test
aA patient without attention deficit hyperactivity disorder (ADHD), Bipolar I Disorder (BID) and ADHD+ BID may have other psychiatric disorders such as Oppositional Defiant Disorder (ODD), Major Depressive Disorder (MDD), obsessive compulsive disorder (OCD)
Table 3 shows the distribution of various methods of self-harm in general and by gender. Wounding or cutting a part of the body was the highest percentage among self-harms (56(40%)). Biting (P.value = 0.002), Preventing wounds from healing (P.value = 0.059), Needling oneself (P.value = 0.032) and Ingestion of dangerous substances (P.value = 0.039) statistically significant difference was seen between boys and girls. All methods were more common in girls than boys.
Table 3.
Distribution of various methods of self-harm based on gender
| Various methods of self-harm | Total N(%) | Gender | P value* | ||
|---|---|---|---|---|---|
| Male | Female | ||||
| Wounding or cutting a part of the body | Yes | 56(71.8) | 16(28.6) | 40(71.4) | 0.293 |
| No | 22(28.2) | 9(40.9) | 13(59.1) | ||
| Biting | Yes | 25(32.1) | 2(8.0) | 23(92.0) | 0.002 |
| No | 53(67.9) | 23(43.4) | 30(56.6) | ||
| Burning | Yes | 9(11.5) | 2(22.2) | 7(77.8) | 0.502 |
| No | 69(88.5) | 23(33.3) | 46(66.7) | ||
| Tearing up | Yes | 22(28.2) | 8(36.4) | 14(63.6) | 0.609 |
| No | 56(71.8) | 17(30.4) | 39(69.6) | ||
| Pinching | Yes | 13(16.7) | 2(15.4) | 11(84.6) | 0.158 |
| No | 65(83.3) | 23(35.4) | 42(64.6) | ||
| Plucking hair | Yes | 27(34.6) | 5(18.5) | 22(81.5) | 0.062 |
| No | 51(65.4) | 20(39.2) | 31(60.8) | ||
| Grabbing oneself | Yes | 29(37.2) | 6(20.7) | 23(79.3) | 0.098 |
| No | 49(62.8) | 19(38.8) | 30(61.2) | ||
| Hitting oneself | Yes | 49(63.6) | 14(28.6) | 35(71.4) | 0.334 |
| No | 28(36.4) | 11(39.3) | 17(60.7) | ||
| Preventing wounds from healing | Yes | 26(33.3) | 12(46.2) | 14(53.8) | 0.059 |
| No | 52(66.7) | 13(25.0) | 39(75.0) | ||
| Pulling skin on hard surfaces | Yes | 13(16.7) | 3(23.1) | 10(76.9) | 0.448 |
| No | 65(83.3) | 22(33.8) | 43(66.2) | ||
| Needling oneself | Yes | 9(11.7) | 0(0.0) | 9(100.0) | 0.032 |
| No | 68(88.3) | 24(35.3) | 44(64.7) | ||
| Ingestion of dangerous substances | Yes | 17(22.1) | 2(11.8) | 15(88.2) | 0.039 |
| No | 60(77.9) | 23(38.3) | 37(61.7) | ||
| Other self-injurious behaviors | Yes | 12(15.4) | 4(33.3) | 8(66.7) | 0.918 |
| No | 66(84.6) | 21(31.8) | 45(68.2) | ||
*Chi-square
Table 4 shows the distribution of frequency of non-suicidal self-injurious methods, by most common psychiatric disorders. As shown in the table, Wounding or cutting a part of the body (P.value = 0.037),Biting (P.value = 0.022),Burning (P.value = 0.043), Pinching (P.value = 0.008), and Plucking hair (P.value = 0.010) are statistically different among the most common psychiatric disorders, and most of them are more common in the diagnosis of ADHD + BID.
Table 4.
Distribution of frequency of non- suicidal self-injurious methods, by most common psychiatric disorders(N(%))
| Disorder | Without the most common psychiatric disordersa | ADHD | BID | ADHD + BID | P value* | |
|---|---|---|---|---|---|---|
| Wounding or cutting a part of the body | Yes | 13(23.2) | 9(16.1) | 17(30.4) | 17(30.4) | 0.037 |
| No | 7(31.8) | 9(40.9) | 2(9.1) | 4(18.2) | ||
| Biting | Yes | 10(40.0) | 7(28.0) | 1(4.0) | 7(28.0) | 0.022 |
| No | 10(18.9) | 11(20.8) | 18(34.0) | 14(26.4) | ||
| Burning | Yes | 1(11.1) | 1(11.1) | 1(11.1) | 6(66.7) | 0.043 |
| No | 19(27.5) | 17(24.6) | 18(26.1) | 15(21.7) | ||
| Tearing up | Yes | 7(31.8) | 3(13.6) | 6(27.3) | 6(27.3) | 0.626 |
| No | 13(23.2) | 15(26.8) | 13(23.2) | 15(26.8) | ||
| Pinching | Yes | 8(61.5) | 3(23.1) | 1(7.7) | 1(7.7) | 0.008 |
| No | 12(18.5) | 15(23.1) | 18(27.7) | 20(30.8) | ||
| Plucking hair | Yes | 11(40.7) | 4(14.8) | 2(7.4) | 10(37.0) | 0.010 |
| No | 9(17.6) | 14(27.5) | 17(33.3) | 11(21.6) | ||
| Grabbing oneself | Yes | 11(37.9) | 5(17.2) | 5(17.2) | 8(27.6) | 0.224 |
| No | 9(18.4) | 13(26.5) | 14(28.6) | 13(26.5) | ||
| Hitting oneself | Yes | 16(32.7) | 10(20.4) | 10(20.4) | 13(26.5) | 0.280 |
| No | 4(14.3) | 8(28.6) | 9(32.1) | 7(25.0) | ||
| Preventing wounds from healing | Yes | 8(30.8) | 2(7.7) | 7(26.9) | 9(34.6) | 0.147 |
| No | 12(23.1) | 16(30.8) | 12(23.1) | 12(23.1) | ||
| Pulling skin on hard surfaces | Yes | 4(30.8) | 1(7.7) | 4(30.8) | 4(30.8) | 0.550 |
| No | 16(24.6) | 17(26.2) | 15(23.1) | 17(26.2) | ||
| Needling oneself | Yes | 5(55.6) | 0(0.0) | 1(11.1) | 3(33.3) | 0.085 |
| No | 15(22.1) | 18(26.5) | 17(25.0) | 18(26.5) | ||
| Ingestion of dangerous substances | Yes | 6(35.3) | 5(29.4) | 1(5.9) | 5(29.4) | 0.266 |
| No | 14(23.3) | 13(21.7) | 17(28.3) | 16(26.7) | ||
| Other self-injurious behaviors | Yes | 4(33.3) | 2(16.7) | 1(8.3) | 5(41.7) | 0.359 |
| No | 16(24.2) | 16(24.2) | 18(27.3) | 16(24.2) | ||
*Chi-square
aA patient without attention deficit hyperactivity disorder (ADHD), Bipolar I Disorder (BID) and ADHD+ BID may have other psychiatric disorders such as Oppositional Defiant Disorder (ODD), Major Depressive Disorder (MDD), obsessive compulsive disorder (OCD)
Discussion
According to the results of the ongoing study, the prevalence of self-injury among adolescents with psychiatric disorders was 99 (70.7%) out of 140 individuals, which is consistent with previous studies, the 2021 study by Jong, which found the prevalence of self-injury in psychiatric units to be approximately 60% [14]. Of the 99 adolescents with a history of NSSI, 35 (35.4%) were boys and 64(75.3%) were girls. The prevalence of self-injury was higher in girls than in boys. This finding is also similar to the 2021 study by Jong et al. [14] and the 2018 study by Lauw et al. [15], in which the NSSI prevalence was higher among female adolescents.
Overall, 65(46.4%) cases were inpatient and 75 (53.6%) were outpatient. There was not significant association between self-injury and inpatient or outpatient status. Previous studies did not compare the prevalence of self-injury between inpatients and outpatients, and this finding seems to be novel in this field. However, this does not preclude the possibility of an indirect or complex relationship that requires further investigation. Future research could examine the role of mediating or moderating factors that may influence the relationship between outpatient and inpatient status, such as NSSI symptom severity, presence of comorbid disorders, or quality of outpatient care.
According to the results of the present study, self-injury was most prevalent in individuals who had diagnoses of ADHD. ADHD + BID ranked second and BID ranked third. But in the study by Goodwin et al. [16], the high rate of NSSI in patients with bipolar disorder, which reported that more than 60% of individuals with bipolar disorder engaged in self-injurious behavior at least once in their lifetime. Also, the high prevalence of self-injury in patients with ADHD, either as a stand-alone diagnosis or as a concurrent diagnosis with bipolar disorder, is consistent with the studies of Barkley [17]and Steinberg et al. [18], according to which the expression of ADHD can be a risk factor for self-injury (through deficits in executive functions, it causes disturbances in inhibition and emotion regulation). Since bipolar disorder also involves a disorder of emotion control and regulation, this effect is greater in the simultaneous presence of two disorders, which may justify the high prevalence of self-injury in the simultaneous presence of the two disorders mentioned in the current study. In fact, our study investigated NSSI motives in adolescents with psychiatric disorders. Our findings provide valuable insights into the prevalence of specific motives, such as emotional dysregulation and self-punishment, in this study group. Therefore, it appears that interventions targeting emotion regulation skills may be useful in reducing NSSI behaviors. This is consistent with previous research showing the effectiveness of cognitive-behavioral therapy (CBT) for adolescents struggling with emotional dysregulation and self-harm [19].
The results of the present study suggested that in comorbid ADHD and bipolar disorder, emotion regulation, and belonging to peers were the most common motivations of patients. In bipolar disorder, emotion regulation, self-punishment, expression of confusion, and distinguishing oneself from others were the most important motivations. In ADHD, emotion regulation, self-punishment, expression of confusion, and demonstration of power were the most important motivations. In general, emotion regulation was the most important motivation for NSSI behavior present in all groups. Many studies have indicated that emotion regulation is the most important and common motivation for NSSI behavior. Katz [20] reported that 60% of adolescents experience a sense of emotional release after self-injury. Chapman et al. [9] noted that many people self-mutilate to try to regulate their internal emotions and reduce their psychological turmoil through an external cry for help. In a 2017 study on 856 adolescents with psychiatric disorders, the most common reason given was that they wanted to get out of a terrible mental situation. Emotion regulation, self-punishment, and anti-suicide were also cited [21]. Despite the fact that emotion regulation was the most common and important motivation for self-injury in all patient groups, it is noteworthy that all adolescents in the present study mentioned several other important motivations and functions. According to the present study, self-injurious behavior depends on several factors and motivations. As in previous studies, e.g. the 2008 study by Nock et al. [22], it was shown that most adolescents gave several reasons for self-injury and that this maladaptive behavior actually meets several types of people’s needs. Gratz [23] conducted a study on female inpatients in the psychiatric ward and found that most women gave several reasons for self-injury, including emotion regulation, relieving tension, discharging anger, creating a pleasant state, and as a means of communication. In his study, as in the present study, emotion regulation was the most important motivation for self-injury, and several motivations for this behavior were identified. Studying and understanding the motivations for self-injury will be an effective aid in treating this behavior because for treatment we need to know the function of the behavior and consider a useful alternative method. As an important point in this case, we mention the anti-suicide function of this behavior. One of the motivations for self-injury in almost all people is the anti-suicide function. Therefore, before treating self-injurious behavior, it is necessary to teach the person suicide prevention strategies so that suicidal self-injury does not increase as a result of the treatment.
As far as emotional regulation is concerned, it can be said that most of these people do not know appropriate adaptive methods in the face of problems and therefore use the inappropriate maladaptive method of self-injury. Indeed, learning adaptive methods helps to regulate emotions and thus heal self-injury. The motives of this behavior can be used in treatments such as dialectical behavioral therapy, cognitive behavioral therapy, and mentalization-based treatments, which are called treatments for this disorder.
Similar to the results of our study, cutting a part of the body or wounding was the most common method of injury, which was found in many studies in the past. In a study conducted by Lauw et al. in 2018, wounding or cutting a part of the body was the most common method of self-injury [15]. In another study conducted by Khanipour et al., cutting parts of the body with a sharp object was reported as the most common method [24]. In a study conducted by Mohammadpourasal et al. in Tabriz on male high school students, cutting a part of the body and burning were the most common types of injuries [25], which is different from the findings of the current study regarding burning. This difference could be due to the culture of this society or the gender of the study, as it was conducted only on boys.
Contrary to public opinion that self-injury is limited to cutting or wounding a part of the body, it is important to know that there are different methods of self-injury, and it is necessary to consider all types of self-injury in order to make a more accurate diagnosis.
Limitations of the research
Limitations of the study included the lack of a control group, the use of self-report in data collection, and the smaller number of individuals with certain diagnoses compared to other diagnoses, which could affect the results.
Suggestions
To ensure safe generalization, it is suggested that the current study be conducted with a larger statistical population and a control group (adolescents without psychiatric disorders) to determine the overall prevalence of NSSI behavior and to select a larger statistical population so that the number of patients in each diagnostic group is higher and the results are more reliable.
The results of the present study can be used to treat NSSI behavior. First, because of the high prevalence of this behavior in some psychiatric disorders such as bipolar disorder and ADHD, timely diagnosis and treatment of these disorders may reduce the occurrence of these behaviors. For example, screening elementary school-aged children for ADHD can have a major impact on preventing these behaviors in the future. Second, non-pharmacological treatments can be used to regulate emotions, which was the most important function of self-injury in the current study. Learning adaptive behaviors is an important example of these effective treatments.
Conclusions
NSSI in adolescents is not limited to a specific or single motive, but multiple motives play a role in the occurrence of this behavior. The NSSI methods may also vary, and all should be considered when examining this behavior. The attention-deficit/hyperactivity disorder is the most common psychiatric diagnosis in people with a history of NSSI.
Acknowledgements
This study was conducted at Babol University of Medical Sciences with funding from the Deputy of Research and Technology with the code 9911851. The authors are deeply indebted to the children and their parents who helped us in this study.
Abbreviations
- NSSI
Non-suicidal self-injury
- ADHD
Attention-deficit/hyperactivity disorder
- K- SADS-PL
Kiddie Schedule for Affective Disorders and Schizophrenia Present and Life Time Version
- BID
Bipolar I Disorder
- ODD
Oppositional Defiant Disorder
- MDD
Major Depressive Disorder
- OCD
Obsessive Compulsive Disorder
- CBT
Cognitive-Behavioral Therapy
Authors’ contributions
AM is the chief investigator who, together with ZA, SM, and HSH designed the study. All study authors contributed to the development of the final study protocol. AM and ZA coordinated the study SM and HSH led the collection of study data. AM, and HSH developed the Statistical Analysis Plan and led statistical analysis and modelling. All authors had full access to to study data, commented on and approved the final version of this manuscript and accept responsibility to submit for publication.
Funding
This study was conducted at Babol University of Medical Sciences with funding from the Deputy of Research and Technology with the code 9911851.
Data availability
The data used during the current study are available from the corresponding author on reasonable request.
Declarations
Ethics approval and consent to participate
Informed consent was obtained from the legal guardians of all participants under the age of 18, as they were unable to provide consent themselves. The ongoing study was approved by the Ethics Committee of Babol University of Medical Sciences (IR.MUBABOL.REC.1400.010) and all experimental protocols were approved by Babol University of Medical Sciences.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
References
- 1.Liu RT, Walsh RFL, Sheehan AE, Cheek SM, Sanzari CM. Prevalence and Correlates of Suicide and Nonsuicidal Self-injury in Children: A Systematic Review and Meta-analysis. JAMA Psychiatry. 2022;79(7):718–26. 10.1001/jamapsychiatry.2022.1256. [DOI] [PMC free article] [PubMed]
- 2.Brown RC, Plener PL. Non-suicidal self-injury in adolescence. Curr Psychiatry Rep. 2017;19:1–8. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Cipriano A, Cella S, Cotrufo P. Nonsuicidal self-injury: a systematic review. Front Psychol. 2017;8:1946. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Pivastegar M. The rate of deliberate self- harming in girls students and relationship with loneliness & attachment styles. J Psychol Stud. 2013;9(3):29–52.
- 5.Swannell SV, Martin GE, Page A, Hasking P, St John NJ. Prevalence of nonsuicidal self-injury in nonclinical samples: systematic review, meta-analysis and meta-regression. Suicide Life Threat Behav. 2014;44(3):273–303. [DOI] [PubMed] [Google Scholar]
- 6.Domingues PN, Da Silva TF. Prevalence and correlates of Self-Injury among adolescents: a cross-sectional study. Int J Clin Psychiatry Mental Health. 2022;10:6–12.
- 7.Heilbron N, Prinstein MJ. Adolescent peer victimization, peer status, suicidal ideation, and nonsuicidal self-injury: examining concurrent and longitudinal associations. Merrill Palmer Q (Wayne State Univ Press). 2010;56(3):388. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Bryan CJ, Bryan AO, May AM, Klonsky ED. Trajectories of suicide ideation, nonsuicidal self-injury, and suicide attempts in a nonclinical sample of military personnel and veterans. Suicide Life Threat Behav. 2015;45(3):315–25. [DOI] [PubMed] [Google Scholar]
- 9.Chapman AL, Gratz KL. Freedom from self-harm: overcoming self-injury with skills from DBT and other treatments. Oakland: New Harbinger; 2009.
- 10.Clements C, Morriss R, Jones S, Peters S, Roberts C, Kapur N. Suicide in bipolar disorder in a national English sample, 1996–2009: frequency, trends and characteristics. Psychol Med. 2013;43(12):2593–602. [DOI] [PubMed] [Google Scholar]
- 11.Turner BJ, Chapman AL, Layden BK. Intrapersonal and interpersonal functions of non suicidal self-injury: associations with emotional and social functioning. Suicide Life Threat Behav. 2012;42(1):36–55. [DOI] [PubMed] [Google Scholar]
- 12.Klonsky ED, Glenn CR, Styer DM, Olino TM, Washburn JJ. The functions of nonsuicidal self-injury: converging evidence for a two-factor structure. Child Adolesc Psychiatry Menta Health. 2015;9(1):1–9. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Gsdg D, Fdsgsdfg D, Jhgghj G. Non-suicidal self-injury in delinquent adolescents and adolescents with history of childhood maltreatment: motivation and suicide probability. Psychol Except Individua. 2016;6(21):59–79. [Google Scholar]
- 14.Jong C-L, Chou W-J, Yen C-F. Nonsuicidal self-injury in children and adolescents. Taiwan J Psychiatry. 2021;35(4):166–71. [Google Scholar]
- 15.Lauw MSM, Abraham AM, Loh CBL. Deliberate self-harm among adolescent psychiatric outpatients in Singapore: prevalence, nature and risk factors. Child Adolesc Psychiatry Menta Health. 2018;12:1–6. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Goodwin FK, Jamison KR. Manic-depressive illness: bipolar disorders and recurrent depression, vol. 2. New York: Oxford University Press; 2007.
- 17.Barkley RA. Behavioral inhibition, sustained attention, and executive functions: constructing a unifying theory of ADHD. Psychol Bull. 1997;121(1): 65. [DOI] [PubMed] [Google Scholar]
- 18.Steinberg EA, Drabick DAG. A developmental psychopathology perspective on ADHD and comorbid conditions: the role of emotion regulation. Child Psychiatry Hum Dev. 2015;46:951–66. [DOI] [PubMed] [Google Scholar]
- 19.Kranzler A, Fehling KB, Lindqvist J, Brillante J, Yuan F, Gao X, Miller AL, Selby EA. An ecological investigation of the emotional context surrounding nonsuicidal self-injurious thoughts and behaviors in adolescents and young adults. Suicide Life Threat Behav. 2018;48(2):149–59. [DOI] [PubMed] [Google Scholar]
- 20.Katz C. Early trauma, defense, and effects on later development: a discussion of the papers of Anzieu, Mathelin, and Marans, December 2007, at the conference where the wild things are now: exciting and scary things for children and therapists. J Infant Child Adolesc Psychother. 2008;7(3–4):185–91. [Google Scholar]
- 21.Doyle L, Sheridan A, Treacy MP. Motivations for adolescent self-harm and the implications for mental health nurses. J Psychiatr Ment Health Nurs. 2017;24(2–3):134–42. [DOI] [PubMed] [Google Scholar]
- 22.Nock MK, Mendes WB. Physiological arousal, distress tolerance, and social problem-solving deficits among adolescent self-injurers. J Consult Clin Psychol. 2008;76(1): 28. [DOI] [PubMed] [Google Scholar]
- 23.Gratz KL. Risk factors for deliberate self-harm among female college students: the role and interaction of childhood maltreatment, emotional inexpressivity, and affect intensity/reactivity. Am J Orthopsychiatry. 2006;76(2):238–50. [DOI] [PubMed] [Google Scholar]
- 24.Khanipour H, Borjali A, Golzari M, Falsafinejad MR, Hakim-Shushtari M. Self-harm in adolescents with delinquency and history of mood disorder: a qualitative research. J Qualitat Res Health Sci. 2020;2(3):195–207. [Google Scholar]
- 25.Asghar Mohammad P, Ali F, Fatemeh R. The incidence rate of the delibeate self-injury in male high school pupils, Tabriz-Iran. 2009.
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data used during the current study are available from the corresponding author on reasonable request.