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Evidence-based assessment/Self harm (assessment portfolio)

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Type classification: this is an evidence-based assessment resource.

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What is a "portfolio"?

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  • For background information on what assessment portfolios are, click the link in the heading above.
  • Want even 'more' information about this topic? There's an extended version of this page here.

Preparation phase

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It is important to recognize that measures of suicide-related thoughts and behaviors (i.e., suicidal ideation) and non-suicidal self injury (NSSI) are measure distinct constructs. NSSI items often specify a behavior with clarification that the behavior was not undertaken with intent of suicide. This distinction is important when identifying which measure to use to evaluate a client.

Risk assessment

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Here are some questions that could be included as a part of a clinical assessment:

• Have you been thinking about suicide recently? (start with ideation -- most common and least threatening opening question)

• When you think about suicide, what kinds of thoughts do you have? (open-ended question)

• Have you made any plans for attempting suicide? For example, have you obtained the means necessary to complete suicide, like purchasing a gun or obtaining pills? (exploring preparation)

• Do you have confidence that you could attempt suicide?

• Have you ever attempted suicide previously? (gathering past history)

• Have you ever harmed yourself intentionally? For example, cut yourself, swallowed pills, or burned yourself?

• What are some reasons that you would consider attempting suicide?

• Tell me about your support system. Do you feel isolated? Are you able to talk to friends and family about your problems? (Isolation is a risk factor; social support is protective)

• How do you feel when you think about the future? Are you hopeful that you can do something about your problems? (asking about hopelessness, an established risk factor)

Note. List adapted from Table 1 in Cukrowicz, Wingate, Driscoll, & Joiner (2004).[1]

Suicidal Ideation

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Self-Injurious Thoughts and Behaviors Interview[2]. Suicide has an article on Wikipedia.

Diagnostic criteria for NSSI

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DSM-5 Criteria for NSSI

  • Nonsuicidal self-injury is currently a proposed disorder in need of further research in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5)[3].
  • The criteria for NSSI can be found under Conditions for Further Study in DSM-5.

ICD-11 Criteria for NSSI

Intentional self-inflicted injury to the body, most commonly cutting, scraping, burning, biting, or hitting, with the expectation that the injury will lead to only minor physical harm.

  • For ICD-11, self-injury or self-harm is cited as a symptom or sign that is not classified elsewhere

Base rates of NSSI in different populations and clinical settings

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This section describes the demographic setting of the population(s) sampled, base rates of diagnosis, country/region sampled and the diagnostic method that was used. Using this information, clinicians will be able to anchor the rate of the non-suicidal self injuries (NSSI) that they are likely to see in their clinical practice.

  • To see prevalence rates across multiple disorders, click here.
Demography Setting Base Rate Diagnostic Method
International Young adult non-clinical sample 13.4% Meta-analysis, controlling for methodological differences across studies
All of U.S.A. Adult community sample 23% Self-report measure (questions based on proposed DSM-V criteria for NSSI Disorder; FASM)
North East Adolescent inpatient sample 50% Self-report measure (ISAS), based on DSM-V criteria for NSSI Disorder
Sweden Adolescent community sample 43.4% Combined self-report measure (FASM) and interview (SITBI)
U.S.A. Adult outpatient sample 11.4% Chart review, not based on DSM-V criteria
All of U.S.A. Adolescent epidemiological 13.0%-23.2% Variable assessment methods
North East Adolescent non-clinical sample 7.5% Self-report measure
North East Adolescent inpatient sample 60% Self-report measure (FASM)
United Kingdom Incarcerated sample 52% Self-report measure (FASM)
International Adults from sexual minorities (LGBT) samples 36.53% Various self-report questionnaires

Prediction phase

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Psychometric properties of screening instruments of NSSI

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The following section contains a list of screening and diagnostic instruments for non-suicidal self-injury. The section includes administration information, psychometric data, and PDFs or links to the screenings.

  • Screenings are used as part of the prediction phase of assessment; for more information on interpretation of this data, or how screenings fit in to the assessment process, click here.
  • For a list of more broadly reaching screening instruments, click here.
Screening measures for (Self Harm)
Measure Format (Reporter) Age Range Administration/

Completion Time

Where to Access
Suicidal Behaviors Questionnaire (SBQ) [4] Self-report 13-18 5 minutes Printable PDF of SBQ
Beck Scale for Suicide Ideation (BSI) Self-report 17+ 5-10 minutes Link to purchase BSI
Suicide Ideation Questionnaire for Children (SIQ-JR) Self-report 12-15 15 items Link to purchase SIQ-JR

Note: Reliability and validity are included in the extended version. This table includes measures with Good or Excellent ratings.

Likelihood ratios and AUCs of screening measures for NSSI

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  • For a list of the likelihood ratios for more broadly reaching screening instruments, click here.
Screening Measure (Primary Reference) AUC LR+ (score) LR- (score) Clinical Generalizability Download
Child Behavior Checklist (CBCL) Anxious/Depressed Scale T-score[5] .70 (N=470) 3.78 (60+) .39 (<60) High. Large diverse sample with mixed depression sample compared to samples without depression. Not free

Interpreting NSSI screening measure scores

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  • For information on interpreting screening measure scores, click here.

Prescription phase

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Gold standard diagnostic interviews

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  • For a list of broad reaching diagnostic interviews sortable by disorder with PDFs (if applicable), click here.
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Diagnostic instruments for NSSI
Measure Format (Reporter) Age Range Administration Time Where to Access
Suicide Behaviors Questionnaire-Revised (SBQ-R) Self-report 18+ 5-10 mins Link to free download:SBQ-R
Suicide Attempt Self-Injury Interview (SASII) [6] Structured interview 18+ Varies Link to free download:SASII
Self Injurious Thoughts and Behaviors Interview (SITBI) [7] Structured interview 11+ 3-15 mins Link to free download:SITBI

Note: Reliability and validity are included in the extended version. This table includes measures with Good or Excellent ratings.

Process phase

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The following section contains a brief overview of treatment options for depression and list of process and outcome measures for non-suicidal self-injury. The section includes benchmarks based on published norms for several outcome and severity measures, as well as information about commonly used process measures. Process and outcome measures are used as part of the process phase of assessment. For more information of differences between process and outcome measures, see the page on the process phase of assessment.

Outcome and severity measures

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  • This table includes clinically significant benchmarks for NSSI specific outcome measures
  • Information on how to interpret this table can be found here.
  • Additionally, these vignettes might be helpful resources for understanding appropriate adaptation of outcome measures in practice.
  • For clinically significant change benchmarks for the CBCL, YSR, and TRF total, externalizing, internalizing, and attention benchmarks, see here.

Treatment

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Information on treatment for NSSI

According to Nock (2010)[8], no treatment for NSSI could be considered "evidence-based." However, recent years have seen an increase in intervention trials for NSSI. Although limited due to lack of consistency in defining and measuring NSSI, this work could provide insight into potential best practices for treating this condition (Andover, 2015)[9].

  1. Dialectical behavioral therapy (DBT)
    1. Dialectical Behavior Therapy has been shown to be effective in treating individuals with Borderline Personality Disorder (BPD) who engage in NSSI; however it has not been shown to be better than treatment as usual in a sample of individuals without BPD. In the absence of a better option, a DBT approach to treatment is the most evidence based.
  2. Cognitive behavioral therapy (CBT)
    1. Few research studies have tested cognitive-behavioral therapy (CBT) as a treatment specifically for NSSI. However, some studies have evaluated the efficacy of CBT trials in treating self-injury with and without suicidal intent. Manual-assisted cognitive therapy (MACT) is a 6-session CBT intervention focusing on functions of deliberate self-harm, emotion regulation, problem-solving skills, and relapse prevention. MACT has demonstrated mixed results for decreasing NSSI frequency and severity among adults (Tyrer et al., 2003[10]; Weinberg, Gunderson, Hennen, & Cutter, 2006)[11]. Although MACT may be a promising intervention (Muehlenkamp, 2006)[12], it should be evaluated in future studies. In one adolescent treatment trial, the Adolescent Depression Antidepressant Psychotherapy Trial (ADAPT), a decrease in NSSI behaviors was found at post-treatment for both SSRI and SSRI+CBT groups (Goodyer et al., 2007)[13], although no differences were found between groups. In sum, findings from efficacy trials of CBT on NSSI outcomes are mixed, and more trials examining CBT as a treatment specifically for NSSI are needed.
  3. Pharmacology
    1. Pharmacological interventions are especially scarce. However, one study found that fluoxetine was effective at reducing NSSI frequency in a sample of 22 adults with major depressive disorder and either BPD or schizotypal personality disorder (Markovitz et al, 1991)[14]. A second trial found that antidepressant medications alone (SSRIs and SNRIs) were as effective as medication plus CBT in reducing NSSI among adolescents with MDD (Brent et al., 2009[15]; Goodyer et al., 2007)[13]. Ziprasidone, an atypical antipsychotic, was found to be more effective in reducing NSSI behaviors among adolescents compared to another neuroleptic medication (Libal et al., 2005)[16]. Clonidine has also been effective as an intervention for acute NSSI urges and feelings of tension among a sample of patients with BPD (Philipsen et al., 2004)[17], although the long-term effects are unknown.
  4. Prevention programs
    1. Jacobs, Walsh, McDade, and Pigeon (2009)[18] developed the only known prevention program for NSSI, the Signs of Self-Injury program (SOSI). This school-based prevention program is designed to increase awareness about NSSI among adolescents through psychoeducation about warning signs and symptoms and improvement of help-seeking behaviors and attitudes. One test of effectiveness and acceptance found the program to be feasible and effective at changing attitudes toward NSSI and increasing help-seeking among students (Muehlenkamp et al., 2010)[19].

External resources

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  1. Find-a-Therapist (a curated list of find-a-therapist websites where you can find a provide
  2. Cornell resource on self-injury
  3. Effective Child Therapy page for Self-Injurious Thoughts and Behaviors
    1. Effective Child Therapy is website sponsored by Division 53 of the American Psychological Association (APA), or The Society of Clinical Child and Adolescent Psychology (SCCAP) (SCCAP), in collaboration with the Association for Behavioral and Cognitive Therapies (ABCT). Use for information on symptoms and available treatments.
  4. Wikipedia page for non-suicidal self injury
  5. Mental Health First Aid page on non-suicidal self-injury

References

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Click here for references

Liu, R. T., Sheehan, A. E., Walsh, R. F., Sanzari, C. M., Cheek, S. M., & Hernandez, E. M. (2019). Prevalence and correlates of non-suicidal self-injury among lesbian, gay, bisexual, and transgender individuals: A systematic review and meta-analysis. Clinical psychology review, 74, 101783}}

  1. ↑ Cukrowicz, Kelly C.; Wingate, LaRicka R.; Driscoll, Kimberly A.; Joiner, Thomas E. (2004-03-01). "A Standard of Care for the Assessment of Suicide Risk and Associated Treatment: The Florida State University Psychology Clinic as an Example". Journal of Contemporary Psychotherapy 34 (1): 87–100. doi:10.1023/B:JOCP.0000010915.77490.71. ISSN 1573-3564. https://doi.org/10.1023/B:JOCP.0000010915.77490.71. 
  2. ↑ Nock, Matthew K.; Holmberg, Elizabeth B.; Photos, Valerie I.; Michel, Bethany D. (2007). "Self-Injurious Thoughts and Behaviors Interview: Development, reliability, and validity in an adolescent sample.". Psychological Assessment 19 (3): 309–317. doi:10.1037/1040-3590.19.3.309. ISSN 1939-134X. http://doi.apa.org/getdoi.cfm?doi=10.1037/1040-3590.19.3.309. 
  3. ↑ American Psychiatry Association (2013). Diagnostic and statistical manual of mental disorders : DSM-5 (5th ed.). Washington [etc.]: American Psychiatric Publishing. ISBN 9780890425558. 
  4. ↑ Linehan, M. M. (1981). Suicides behaviors questionnaire. Seattle: University of Washington. 
  5. ↑ Achenbach, Thomas M. (1991). Child behavior checklist for ages 4-18 ([11th print.] ed.). Burlington, VT: T.M. Achenbach. ISBN 0938565087. 
  6. ↑ Linehan, MM; Comtois, KA; Brown, MZ; Heard, HL; Wagner, A (September 2006). "Suicide Attempt Self-Injury Interview (SASII): development, reliability, and validity of a scale to assess suicide attempts and intentional self-injury.". Psychological assessment 18 (3): 303-12. PMID 16953733. 
  7. ↑ Nock, MK; Holmberg, EB; Photos, VI; Michel, BD (September 2007). "Self-Injurious Thoughts and Behaviors Interview: development, reliability, and validity in an adolescent sample.". Psychological assessment 19 (3): 309-17. PMID 17845122. 
  8. ↑ Nock, MK (2010). "Self-injury.". Annual review of clinical psychology 6: 339-63. PMID 20192787. 
  9. ↑ Andover, MS (30 October 2014). "Non-suicidal self-injury disorder in a community sample of adults.". Psychiatry research 219 (2): 305-10. PMID 24958066. 
  10. ↑ Tyrer, P; Thompson, S; Schmidt, U; Jones, V; Knapp, M; Davidson, K; Catalan, J; Airlie, J et al. (August 2003). "Randomized controlled trial of brief cognitive behaviour therapy versus treatment as usual in recurrent deliberate self-harm: the POPMACT study.". Psychological medicine 33 (6): 969-76. PMID 12946081. 
  11. ↑ Weinberg, I; Gunderson, JG; Hennen, J; Cutter CJ, Jr (October 2006). "Manual assisted cognitive treatment for deliberate self-harm in borderline personality disorder patients.". Journal of personality disorders 20 (5): 482-92. PMID 17032160. 
  12. ↑ Muehlenkamp, J. J. (2006). "Empirically supported treatments and general therapy guidelines for non-suicidal self-injury". Journal of Mental Health Counseling 28: 166-185. 
  13. ↑ 13.0 13.1 Goodyer, I; Dubicka, B; Wilkinson, P; Kelvin, R; Roberts, C; Byford, S; Breen, S; Ford, C et al. (21 July 2007). "Selective serotonin reuptake inhibitors (SSRIs) and routine specialist care with and without cognitive behaviour therapy in adolescents with major depression: randomised controlled trial.". BMJ (Clinical research ed.) 335 (7611): 142. PMID 17556431. 
  14. ↑ Markovitz, PJ; Calabrese, JR; Schulz, SC; Meltzer, HY (August 1991). "Fluoxetine in the treatment of borderline and schizotypal personality disorders.". The American journal of psychiatry 148 (8): 1064-7. PMID 1853957. 
  15. ↑ Brent, DA (2009). "The treatment of SSRI-resistant depression in adolescents (TORDIA): in search of the best next step.". Depression and anxiety 26 (10): 871-4. PMID 19798756. 
  16. ↑ Libal, Gerhard; Plener, Paul L.; Ludolph, Andrea G.; Fegert, Joerg M. (June 2005). "Ziprasidone as a Weight-Neutral Alternative in the Treatment of Self-Injurious Behavior in Adolescent Females". Child and Adolescent Psychopharmacology News 10 (4): 1–6. doi:10.1521/capn.2005.10.4.1. 
  17. ↑ Philipsen, A; Richter, H; Schmahl, C; Peters, J; Rüsch, N; Bohus, M; Lieb, K (October 2004). "Clonidine in acute aversive inner tension and self-injurious behavior in female patients with borderline personality disorder.". The Journal of clinical psychiatry 65 (10): 1414-9. PMID 15491247. 
  18. ↑ Jacobs, D; Walsh, B. W.; McCade, M; Pigeon, S (2009). Signs of self-injury prevention manual. Wellesley Hills, MA: Screening for Mental Health. 
  19. ↑ Muehlenkamp, JJ; Walsh, BW; McDade, M (March 2010). "Preventing non-suicidal self-injury in adolescents: the signs of self-injury program.". Journal of youth and adolescence 39 (3): 306-14. PMID 19756992. 
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