Suicide and Life-Threatening Behavior
2012 The American Association of Suicidology
DOI: 10.1111/j.1943-278X.2011.00069.x
1
Intrapersonal and Interpersonal Functions of
Non suicidal Self-Injury: Associations with
Emotional and Social Functioning
B RIANNA J. TURNER, MA, ALEXANDER L. CHAPMAN, PHD, AND BRIANNE
K. LAYDEN, BA
Understanding the functions of nonsuicidal self-injury (NSSI) has important implications for the development and refinement of theoretical models and
treatments of NSSI. Emotional and social vulnerabilities associated with five
common functions of NSSI–emotion relief (ER), feeling generation (FG), selfpunishment (SP), interpersonal influence (II), and interpersonal communication
(IC)–were investigated to clarify why individuals use this behavior in the service of
different purposes. Female participants (n = 162) with a history of NSSI completed online measures of self-injury, emotion regulation strategies and abilities,
trait affectivity, social problem-solving styles, and interpersonal problems. ER
functions were associated with more intense affectivity, expressive suppression,
and limited access to emotion regulation strategies. FG functions were associated
with a lack of emotional clarity. Similar to ER functions, SP functions were associated with greater affective intensity and expressive suppression. II functions were
negatively associated with expressive suppression and positively associated with
domineering/controlling and intrusive/needy interpersonal styles. IC functions
were negatively associated with expressive suppression and positively associated
with a vindictive or self-centered interpersonal style. These findings highlight the
specific affective traits, emotional and social skill deficits, and interpersonal styles
that may render a person more likely to engage in NSSI to achieve specific goals.
Nonsuicidal self-injury (NSSI), defined as the
direct, deliberate destruction of body tissue
without suicidal intent (Chapman, Gratz, &
Brown, 2006; Gratz, 2003, 2006; Klonsky,
Oltmanns, & Turkheimer, 2003; Nock,
Joiner, Gordon, Lloyd-Richardson, & Prinstein, 2006), is an important health concern in
both clinical and community settings.
Research suggests that the prevalence of this
BRIANNA J. TURNER, ALEXANDER L. CHAPand BRIANNE K. LAYDEN, Department of Psychology, Simon Fraser University, Burnaby, BC,
Canada.
Address correspondence to Brianna J.
Turner, Department of Psychology, Simon Fraser
University, 8888 University Drive, Burnaby, BC,
Canada V5A 1S6; E-mail: [email protected]
MAN,
behavior is as high as 20% to 30% in vulnerable populations, including youth and young
adults (Gratz, 2001; Laye-Gindhu & Schonert-Reichl, 2005), forensic populations
(Brooker, Repper, Beverley, Ferriter, &
Brewner, 2002; Chapman, Specht, & Cellucci, 2005), and psychiatric patients (Briere &
Gil, 1998). NSSI is associated with negative
consequences in several domains, including
risk of infection and scarring, emotional consequences such as shame and guilt (Leibenluft, Gardner, & Cowdry, 1987), social
consequences such as rejection and stigmatization by peers (Favazza, 1998), and increased
risk of suicide (Esposito, Spirito, Boergers, &
Donaldson, 2003; Joiner et al., 2005).
Research examining NSSI as a distinct clinical
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FUNCTIONS OF NSSI, EMOTIONAL AND SOCIAL FUNCTIONING
phenomenon has dramatically increased over
the past 15 years, with growing efforts made
to clarify the phenomenology and etiology of
this behavior (Nock, 2009).
Recent theoretical and empirical models of NSSI have emphasized the functions
of NSSI (Chapman et al., 2006; Nock &
Prinstein, 2004). Understanding how a
behavior functions has important implications for treatment development and implementation, as functions directly point
researchers and clinicians in the direction of
potentially effective interventions. For
instance, if a client reports engaging in NSSI
to reduce anger (i.e., the function is anger
reduction), then treatment might focus on
alternative ways to cope with or tolerate
anger, ways to reduce the likelihood of
anger, and skills to regulate anger. Although
the term function has been operationalized in
a number of ways in the NSSI literature
(i.e., by examining self-reported reasons or
motivations for the behavior, by examining
the consequences of the behavior, and by
examining the emotional and social antecedents of the behavior; see Klonsky, 2007), for
this investigation, we focused on individuals’
self-reported reasons or motives for NSSI.
Although NSSI may also be reinforced by
contingencies that are outside of an individual’s awareness, examining self-reported reasons for NSSI yields important information
regarding the perceived antecedents and
expected consequences of the behavior.
COMMON FUNCTIONS OF NSSI
Theories of the functions of NSSI
have largely emphasized intrapersonal and/
or interpersonal functions. Intrapersonal
functions include changes in one’s internal
state, such as changes in emotional states,
thoughts, and sensations, whereas interpersonal functions include changes in the external environment, such as withdrawal of
demands and increased social support. Two
of the most widely cited functional models of
NSSI are the Four-Factor Model (Nock &
Prinstein, 2004) and the Experiential Avoid-
ance Model (Chapman et al., 2006). According to the Four-Factor Model, the functions
of NSSI can be characterized along two
orthogonal dimensions: the first dimension
describes whether the behavior is reinforced
via internal changes (automatic functions) or
via interpersonal or external changes (social
functions), whereas the second dimension
describes whether NSSI is maintained
through positive or negative reinforcement.
In this article, functions aimed to change
one’s internal state are called intrapersonal
functions, whereas motives aimed at influencing the external environment are called interpersonal functions. By contrast, according to
the Experiential Avoidance Model, NSSI is
primarily maintained through negative reinforcement, involving the avoidance of or
escape from unwanted or intolerable internal
states (emotions, thoughts, sensations, etc.;
Chapman et al., 2006). From this perspective, regulation of inner states is relevant to
instances of NSSI that have positive or negative social consequences. For example, selfinjury that is followed by increased support
and attention may result in alleviation of
loneliness. Similarly, self-injury that is followed by the reduction in demands or aversive behaviors by others may also result in
reductions of negative or unwanted emotional/cognitive states.
Supporting aspects of both models,
the research suggests that people who engage
in NSSI often endorse both intrapersonal
and interpersonal functions. Klonsky (2007)
highlighted seven functions of NSSI: emotion relief (ER), self-punishment (SP), antidissociation, interpersonal influence (II),
peer bonding, sensation seeking, and assertion of interpersonal boundaries. Although
research on the functions of NSSI is still
growing, the extant literature converges in
supporting several conclusions. First, individuals who engage in NSSI often endorse
multiple functions that motivate this behavior (Brown, Comtois, & Linehan, 2002;
Kleindienst et al., 2008; Lloyd-Richardson,
Perrine, Dierker, & Kelley, 2007). Second,
converging evidence suggests that regulation
of emotions is the most commonly and most
TURNER ET AL.
strongly endorsed function of NSSI (Chapman & Dixon-Gordon, 2007; Chapman et
al., 2006; Haines, Williams, Brain, & Wilson, 1995; Klonsky, 2007; Laye-Gindhu &
Schonert-Reichl, 2005; Muehlenkamp &
Gutierrez, 2004; Nock, Prinstein, & Sterba,
2009; Rodham, Hawton, & Evans, 2004;
Schnyder, Valach, & Bischel, 1999). Studies
examining self-reported motives for NSSI
suggest that the most commonly endorsed
motives for NSSI involve relief from aversive
emotional arousal (e.g., ‘‘to decrease uncomfortable feelings e.g., guilt, rage,’’ ‘‘to obtain
relief from a terrible state of mind’’; Brown
et al., 2002; Laye-Gindhu & SchonertReichl, 2005; Schnyder et al., 1999), followed by the generation of feelings in the
presence of aversive numbness or depersonalization (e.g., ‘‘to feel something, even if it
was pain,’’ ‘‘to relieve feeling numb or
empty’’; Gratz, Conrad, & Roemer, 2002;
Laye-Gindhu & Schonert-Reichl, 2005;
Low, Jones, MacLeod, Power, & Duggan,
2000; Nock & Prinstein, 2004). Further, data
from ecological momentary assessment
research on the occurrence of NSSI in peoples’ daily lives also have indicated that emotion regulation functions are the most
frequently reported reason for engaging in
NSSI (Nock et al., 2009).
Findings regarding the frequency and
importance of other functions of NSSI are less
consistent (see Klonsky, 2007, for a review).
For example, self-punishment functions of
NSSI are endorsed by over 50% of participants in some studies, whereas in other studies,
less than 25% of participants endorsed these
functions (Klonsky, 2007). Similarly, some
studies demonstrate moderate to strong
endorsement of anti-dissociation, sensationseeking, anti-suicide, interpersonal influence,
and interpersonal boundary functions, whereas
other studies have found only marginal support for these functions (Klonsky, 2007).
Factors Associated with Intrapersonal
versus Interpersonal Functions
Beyond the clarification of important
functions of NSSI, a newer literature has
3
focused on how intrapersonal and interpersonal functions of NSSI relate to clinical features such as severity and frequency of NSSI,
psychopathology and personality traits, and
social functioning. For example, research
examining the functions of NSSI found that
depressive symptoms, borderline personality
features, suicidal ideation, and engaging in
NSSI when alone were more strongly associated with intrapersonal rather than interpersonal functions, whereas anxiety symptoms
and a history of suicide attempts were significantly associated with both intrapersonal and
interpersonal functions (Klonsky & Glenn,
2009). Moreover, findings from several studies further supported an association of intrapersonal functions of NSSI with symptoms
of depression (Hilt, Cha, & Nolen-Hoeksema, 2008; Kumar, Pepe, & Steer, 2004;
Nock & Prinstein, 2005); one study also supported an association of interpersonal functions and depression (Nock & Prinstein,
2005), suggesting that this relationship is not
unique to intrapersonal functions. Rumination may be a key vulnerability for engaging
in NSSI for intrapersonal functions for some
individuals; among adolescent girls who
engage in NSSI, those who report more
rumination are more likely to engage in
NSSI for anti-dissociation functions when
experiencing depression (Hilt et al., 2008).
When examining specific intrapersonal functions of NSSI, recent suicide attempts and
hopelessness were uniquely associated with
ER functions of NSSI, whereas symptoms of
depression and posttraumatic stress were
associated with feeling generation (FG) functions (Nock & Prinstein, 2005). ER functions
of NSSI are also associated with greater
physiological reactivity in response to a frustrating task (Nock & Mendes, 2008), supporting the notion that individuals who
engage in NSSI to avoid or relieve overwhelming negative emotions may respond
more intensely to stressors.
Endorsement of interpersonal functions of NSSI, on the other hand, has been
associated with several social concerns,
including loneliness (Nock & Prinstein,
2005), socially prescribed perfectionism (i.e.,
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FUNCTIONS OF NSSI, EMOTIONAL AND SOCIAL FUNCTIONING
‘‘beliefs that others maintain exceedingly
high standards of oneself’’; Nock & Prinstein, 2005), and peer victimization (Hilt et
al., 2008). Further, quality of peer communication is negatively associated with II functions of NSSI (Hilt et al., 2008). Adolescent
girls who experience peer victimization and
have poor quality of communication with
peers are more likely to engage in NSSI to
influence others (Hilt et al., 2008). Although
some evidence suggests that individuals who
engage in NSSI demonstrate deficits in social
problem solving (particularly, generating
negative solutions and low confidence that
they could execute a solution successfully;
Nock & Mendes, 2008), research has not yet
examined whether these social skills deficits
are associated with greater endorsement of
interpersonal functions of NSSI. Findings
from these studies suggest that the assessment of the functions of NSSI could be used
to inform clinical hypotheses regarding areas
of dysfunction, associated psychopathology,
and personality functioning, as well as to
inform risk assessment and treatment targets
for individuals engaging in NSSI.
Empirical attempts to delineate subtypes of individuals who engage in NSSI
based on topographical and behavioral features of NSSI have also highlighted the
importance of the functions of NSSI. For
example, one investigation compared individuals who engaged in ‘‘moderate or severe’’
methods of NSSI (i.e., methods that are
more likely to result in acute tissue damage,
such as cutting or burning the skin) with
individuals who engaged in minor methods
of NSSI (i.e., methods that are less likely to
result in acute tissue damage, such as hitting
oneself, biting oneself, pulling one’s hair out;
Lloyd-Richardson et al., 2007). Those who
engaged in moderate/severe methods of
NSSI were more likely to endorse both intrapersonal and interpersonal functions,
whereas individuals who engaged in minor
NSSI endorsed primarily ER (e.g., ‘‘to stop
bad feelings’’) and FG (e.g., ‘‘to feel something even if it was pain’’; Lloyd-Richardson
et al., 2007) functions. Furthermore, a latent
class analysis examining the method (e.g.,
cutting, burning, etc.), social context (e.g.,
alone versus with others), and functions of
NSSI (intrapersonal versus interpersonal)
revealed that function may play an important
role in differentiating clinically distinct subtypes of individuals who engage in NSSI
(Klonsky & Olino, 2008). Particularly, of the
two subgroups characterized by more severe
forms of NSSI, one group engaged in a
greater variety of methods of NSSI, reported
more severe anxiety symptoms, and endorsed
both intrapersonal and interpersonal functions with equal frequency, whereas the other
class engaged primarily in cutting, engaged
in NSSI when alone, and endorsed intrapersonal functions almost exclusively.
Taken together, these findings suggest
that the functions of NSSI play an important
role in the clinical presentation of NSSI.
Specifically, the endorsement of intrapersonal functions of NSSI may indicate a clinical presentation marked by increased
hopelessness and anxiety, increased suicidality, and propensity to engage in more severe
forms of NSSI. In contrast, the endorsement
of interpersonal functions is associated with
negative social relationships, problems with
communication, and socially prescribed perfectionism. Further examination of how the
functions of NSSI are associated with risk
and protective factors could thus inform case
conceptualization and treatment planning.
THE PRESENT STUDY
We examined whether endorsement of
each of five functions of NSSI [ER, FG, SP,
II, and interpersonal communication (IC)]
was associated with specific emotional vulnerabilities and difficulties in social functioning. We focused on ER, FG, SP, II, and IC
functions as these functions have been most
commonly examined in the literature (Chapman et al., 2006; Hilt et al., 2008; Klonsky,
2007; Nock & Prinstein, 2004, 2005) and
may be associated with different social and
emotional vulnerabilities. ER functions
reflect attempts to escape or down-regulate
intense negative emotions (e.g., ‘‘to stop bad
TURNER ET AL.
feelings,’’ ‘‘to relieve feelings of aloneness,
emptiness, or isolation’’). FG functions
reflect attempts to end dissociative states or
numbness, or to up-regulate emotions (e.g.,
‘‘to feel my body again,’’ ‘‘to stop feeling
numb or dead’’). SP functions reflect
attempts to regulate aversive self-focused
emotions (e.g., ‘‘to stop feelings of selfhatred or shame,’’ ‘‘to punish myself’’). II
functions reflect attempts to influence the
behavior or emotions of others (e.g., ‘‘to get
other people to act differently or change,’’
‘‘to get back at or hurt someone’’), whereas
IC functions reflect attempts to convey distress to others (e.g., ‘‘to communicate or let
others know how desperate I am,’’ ‘‘others to
see how badly I am doing’’). We were interested in whether intrapersonal functions (i.e.,
ER, FG, and SP) differed from interpersonal
functions (i.e., II, IC) in their associations
with indices of emotional and social functioning.
To this end, we examined how several
indicators of emotional functioning, including affective intensity and reactivity, emotion
regulation strategies, and difficulties regulating emotions, were associated with each of
the five functions of NSSI. Specifically, we
examined the following hypotheses: (1a) ER
functions of NSSI would be associated with
greater affective intensity and reactivity,
greater expressive suppression, and difficulties in emotion regulation, particularly a lack
of emotion regulation strategies (as defined
by Gratz & Roemer, 2004); (1b) FG functions would be associated with less intense
affect, greater expressive suppression, and
less emotional clarity; (1c) SP functions
would be associated with more intense affect
and greater difficulties with emotion regulation, especially nonacceptance of emotions as
the nonacceptance of emotion may lead to
greater self-directed anger when emotional
reactions are triggered; and (1d) II and IC
functions of NSSI would be associated with
greater affective reactivity (i.e., stronger
emotional responses to evocative stimuli,
such as social stressors) rather than affective
intensity (i.e., stronger baseline or trait levels
of negative emotions), as these functions
5
seem to reflect a tendency to engage in maladaptive coping in response to intense emotional reactions arising from interpersonal
stressors, rather than greater negative affectivity across contexts. Further, we expected
that IC functions would be negatively associated with expressive suppression, as these
functions may indicate greater willingness to
communicate about or display one’s distress.
As a second aim of this study, we
examined how aspects of social functioning,
including problematic interpersonal styles
and social problem-solving abilities, are associated with functions of NSSI. Specifically,
we were interested in whether endorsement
of interpersonal functions of NSSI would be
associated with greater interpersonal problems and greater difficulty solving social
problems. In terms of specific interpersonal
styles that are likely to result in interpersonal
problems, we hypothesized that: (2a) II functions would be associated with domineering
and vindictive interpersonal styles, reflecting
greater need for autonomy and difficulty
managing affiliation in relationships; and
(2b) IC functions would be associated with
nonassertive interpersonal styles, reflecting a
difficulty in directly expressing wants or
needs, which may increase the likelihood that
an individual would rely on NSSI to communicate with others.
METHOD
Participants
Participants were 171 individuals
(n = 162 female; n = 11 male) recruited
from NSSI communities on popular
social networking Web sites such as Facebook.com, LiveJournal.com, and Dailystrength.org. Participants were included if
they endorsed having engaged in NSSI at
any time in the past. Although few studies
have examined gender differences in the
endorsement of various functions of NSSI
(for an exception, see Kumar et al., 2004),
previous research has demonstrated that men
and women differ with respect to affective
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FUNCTIONS OF NSSI, EMOTIONAL AND SOCIAL FUNCTIONING
intensity and reactivity (Flett & Hewitt,
1995; Larsen & Diener, 1987), emotion dysregulation (Shields & Cicchetti, 1998), and
social problem solving (D’Zurilla, MaydeuOlivares, & Kant, 1998). Owing to the small
number of male participants, men were
excluded from subsequent analyses in the
present sample.
Of the female sample, most of the participants resided in the United States
(49.1%), Canada (17.8%), the United Kingdom (14.1%), and Australia (7.4%) at the
time of their participation. Other countries
of residence represented in this sample
include Belgium, Denmark, Germany,
Greece, Israel, Italy, Japan, Mexico, Netherlands, New Zealand, Russia, and South
Africa. The mean age of female participants
was 22.47 years (SD = 7.14) with a range of
16–57 years. Female participants were predominantly White (93.3%). Most participants were attending or had attended college
or university but had not yet completed a
degree (46%), whereas 16% had completed a
college or university degree, 16% had completed high school, and 19.6% were attending high school but had not graduated. Most
participants (69.1%) had received services
from a therapist, counselor, case manager, or
treatment program in the past year; 64.6% of
these participants indicated that they had
received individual therapy or counseling in
the past year, whereas 37.3% indicated they
had seen a psychiatrist.
Procedures
Participants were invited to participate
in an online study examining ‘‘how emotions,
life experiences, stress and coping styles
affect self-harm.’’ Individuals who indicated
their interest in participating were provided
with a password for the secure online questionnaire. After consenting to participate,
participants completed several self-report
questionnaires by selecting or typing
responses to various questions. The study
took approximately 2 hours to complete. To
manage any distress from filling out these
questionnaires, participants completed a
positive mood induction at the end of the
study and were provided with contact information for several international crisis hotlines. After they had completed the study,
participants received a choice of online gift
certificates valued at $5 CAD for a variety of
online organizations (e.g., Amazon.com or
PayPal.com).
Measures
Nonsuicidal Self-Injury. Experiences
with NSSI were assessed using an adapted,
translated English version (two rounds of forward and back translations were conducted
to ensure fidelity to the original measure) of
the Questionnaire for Non-Suicidal SelfInjury (QNSSI; Kleindienst et al., 2008).
This questionnaire assesses the frequency,
methods, and functions of NSSI, as well as
expectations and emotions related to NSSI.
We supplemented the functional items on
the QNSSI (n = 17) with items from the Suicidal Attempt Self-Injury Interview (SASII;
Linehan, Comtois, Brown, Heard, & Wagner, 2006; n = 22) to investigate functions
that were not covered on the QNSSI (e.g., I
want… ‘‘to feel something, even if it was
pain,’’ ‘‘to communicate to or let others know
how desperate I am,’’ ‘‘to get out of doing
something’’), resulting in a final set of 39
functions. Participants were asked to rate the
expectations they connected with self-injury
on a 5-point scale indicating how often
each participant engaged in NSSI in the service of each function (1 = Never to
5 = Always). Previous research with the SASII
has used four theoretically derived scales
(ER, FG, II, and Escape/Avoidance) which
have demonstrated internal consistency values ranging from unacceptable (e.g., Escape/
Avoidance a = .35) to acceptable (e.g., II
a = .80; Brown et al., 2002).
Difficulties Regulating Emotions. Emotion dysregulation was assessed using the
Difficulties in Emotion Regulation Scale
(DERS; Gratz & Roemer, 2004). The DERS
consists of 36 items and is designed to
assess difficulties regulating emotions across
six domains: nonacceptance of negative
TURNER ET AL.
emotions, inability to engage in goal directed
behaviors when experiencing negative
emotions, difficulties controlling impulsive
behavior when experiencing negative emotions, limited access to emotion regulation
strategies, lack of emotional awareness, and
lack of emotional clarity. Previous research
supports the internal consistency (a = .93),
test–retest reliability, and construct and predictive validity of the DERS (Gratz & Roemer,
2004). In this study, the total scale had excellent internal consistency (a = .90), and all
subscales were acceptable (a = .79 to a = .93).
Emotion Regulation Strategies. Emotion regulation strategies were assessed using
the Emotion Regulation Questionnaire
(ERQ; Gross & John, 2003). The ERQ consists of 10 items assessing the use of two emotion regulation strategies: cognitive reappraisal
(six items) and expressive suppression (four
items). Previous research has supported the
factor structure, internal consistency (a = .68
to a = .82), test–retest reliability, and convergent validity of the ERQ in undergraduate
students (Gross & John, 2003). In this study,
the internal consistency of the cognitive
reappraisal and expressive suppression scales
ranged from marginally acceptable to acceptable (as = .85 and .65, respectively).
Affect Intensity. Intensity and reactivity of emotional experiences was assessed
using the 40-item Affect Intensity Measure
(AIM; Larsen, 1984; Larsen & Diener,
1987). The AIM yields an overall score, and
research has supported a three-factor solution, with subscales assessing Positive Affectivity (e.g., ‘‘when I accomplish something
difficult I feel delighted or elated’’), Negative
Intensity (e.g., ‘‘my friends would probably
say I’m a tense or ‘high-strung’ person’’), and
Negative Reactivity (e.g., ‘‘the sight of someone who is hurt badly affects me strongly’’;
Bryant, Yarnold, & Grimm, 1996). In this
study, we were concerned only with the
intensity and reactivity of negative affective
experiences. Studies support the internal
consistency (a = .68 to a = .94; Flett & Hewitt, 1995; Fujita, Diener, & Sandvik, 1991),
test–retest reliability, and construct validity
of the AIM (Flett & Hewitt, 1995; Fujita et
7
al., 1991; Larsen, 1984; Larsen & Diener,
1987). In the present sample, the Negative
Intensity and Negative Reactivity scales
demonstrated marginally acceptable internal
consistencies (a = .64 and .66, respectively).
Social Problem Solving. Social problem
solving was assessed using the Social Problem Solving Inventory–Revised (SPSI-R;
D’Zurilla, Nezu, & Maydeu-Olivares, 2002),
a 52-item self-report inventory of an individual’s ability to identify social problems, generate and compare solutions, make decisions,
and implement solutions. The SPSI-R
includes items such as ‘‘I feel threatened and
afraid when I have an important problem to
solve’’ and ‘‘when I am faced with a difficult
problem I go to someone else for help on
solving it.’’ The SPSI-R has nine subscales:
(1) Positive Problem Orientation, (2) Negative Problem Orientation, (3) Problem Definition and Formulation, (4) Generation of
Alternative Solutions, (5) Decision Making,
(6) Impulsivity/Carelessness Style, (7) Avoidance Style, (8) Rational Problem Solving,
and (9) Solution Implementation and Verification. Among undergraduate students, the
subscales have demonstrated acceptable test–
retest reliability over 3 weeks (r = .72 to
r = .88) and acceptable internal consistency
(a = .72 to a = .92; D’Zurilla et al., 2002). In
this study, the subscales demonstrated
acceptable internal consistency (a = .79–.93).
Interpersonal Problems. Interpersonal
difficulties were assessed using the Inventory
of Interpersonal Problems, 64-item version
(IIP-64; Horowitz, Alden, Wiggins, & Pincus, 2000). The IIP-64 is based on Wiggins
(1979) circumplex model of personality,
which combines two orthogonal, bipolar
dimensions: a vertical dimension representing dominance, status, or control and a
horizontal dimension representing love,
warmth, or affiliation. The IIP-64 consists of
eight scales, of eight items each, corresponding to the eight problematic interpersonal
styles: Domineering/Controlling (PA), Vindictive/Self-Centered (BC), Cold/Distant
(DE), Socially Inhibited (FG), Nonassertive/
Passive (HI), Overly Accommodating/
Exploitable (JK), Self-Sacrificing/Overly
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FUNCTIONS OF NSSI, EMOTIONAL AND SOCIAL FUNCTIONING
Nurturing (LM), and Intrusive/Needy (NO).
Previous research has supported the internal
consistency of the IIP scales (a = .68–.88;
Hess, Rohlfing, Hardy, Glidden-Tracey, &
Tracey, 2010; Horowitz et al., 2000). In this
study, the IIP scales demonstrated acceptable
reliability (a = .73 to a = .89), with the
exception of the Overly Accommodating/
Exploitable subscale (a = .59).
Data Analytic Approach
Our measure of functions of NSSI
included 22 items from the SASII, as well as
17 items from the QNSSI. Previous work
using the items from the SASII (formerly
called the Parasuicide History Interview) has
used theoretically derived scales (Brown et
al., 2002); however, some of these scales
demonstrated low internal consistency (e.g.,
Escape/Avoidance a = .35) and there seemed
to be considerable conceptual overlap
between the Escape/Avoidance and ER subscales. Further compounding the problem is
a lack of data on the differential association
of the items with their respective subscale.
Given these limitations and the fact that the
factor structure of these items has not previously been empirically investigated, we used
an exploratory factor analysis (EFA) with
orthogonal rotation to examine the factor
structure of the QNSSI, with the Kaiser rule
(eigenvalues > 1) guiding factor retention. In
addition, only factors with at least three
items with factor loadings greater than 0.4
were retained to reduce subscales with poor
item representation (see Costello & Osbourne, 2005); items that loaded greater than
0.4 on more than one factor were eliminated.
Following the EFA, we calculated a
mean score of the items comprising each factor to index each function of NSSI. Correlational and hierarchical regression analyses
were conducted separately for variables
related to emotional functioning and those
related to social functioning. We first conducted Pearson product moment correlations
to examine the zero-order associations
between functions of NSSI and the variables
of interest. Because we were conducting a
large number of correlational tests, we used
Bonferroni corrections for each family of correlational tests to hold the probability of making a type I error to an upper bound of a = .05.
We defined a family of tests as total number of
variables that could be entered into each
regression equation; because the total scores
of each measure were not considered for inclusion in the regressions, we did not include the
total scores in our families (e.g., DERS total,
SPSI total, IIP total). For example, there were
10 possible emotional functioning scales that
could be entered into each hierarchical regression, so the cut-off for statistical significance
for the related zero-order correlations was set
at a = .05/10 = .005. For the social functioning variables, there were 18 possible variables,
therefore a = .05/18 = .003.1 Next, we used
hierarchical regressions for these zero-order
correlations to examine which variables contributed unique variance in predicting the
endorsement of each function. In all cases,
lifetime frequency of NSSI was entered in the
first block (to determine whether function
variables are associated with interpersonal or
emotional functioning beyond history of
NSSI), and variables that were significant at
the zero-order level (based on Bonferronicorrected cut-offs) were entered in subsequent
blocks of the regression. For the regression
analyses, our goal was to examine the variance
contributed by successively more specific
problems after accounting for more general
problems. Thus, for the emotional analyses,
we entered affective traits in the second block
as these were conceptualized as the broadest
emotional variable. General emotion regulation strategies were entered in the third block,
and specific difficulties in emotion regulation
were entered in the fourth block. For the social
1
Although our goal was to reduce the probability of making a type I error in the correlational
analyses, we elected not to use a more stringent
cut-off (e.g., a = .001) because we aimed to examine the impact of a broad set of variables in the
hierarchical regression. Essentially, the more
restrictive the criterion for significance in the correlational analyses, the more lenient the criterion
in the regression analyses as fewer variables would
be entered in each regression and thus each step
would control for fewer variables.
TURNER ET AL.
functioning analyses, problematic interpersonal styles were entered in the second block
and specific social problem-solving skills were
entered in the third block. Power calculations
revealed that with a set at .05 and 5 of a possible 10 predictors in a hierarchical regression
being tested, our observed power to detect an
effect of f2 = 0.15 was 0.97, whereas observed
power to detect an effect of f2 = 0.10 was 0.88.
RESULTS
Exploratory Factor Analysis
An initial principal axis factoring with
orthogonal rotation revealed six items that
had low communalities (< 0.4); these items
were removed and the EFA was repeated.
The Kaiser–Meyer–Olkin coefficient suggests
acceptable
sampling
adequacy
(KMO = 0.76). The initial solution revealed
10 factors with eigenvalues greater than one,
accounting for 72.31% of the variance. However, only five of these factors had at least
three items that strongly (i.e., factor loading
>0.4) and uniquely (e.g., no factor loadings
>0.4 on other factors) loaded on the factor.
Therefore, five factors were retained,
accounting for 53.59% of the variance. Items
were reviewed, and the following scales were
identified based on the conceptual content of
each factor: ER (n items = 9, a = .85), FG
(n items = 4, a = .85), II (n items = 3,
a = .83), IC (n items = 3, a = .76), and SP
(n items = 3, a = .66). Intercorrelations
among the subscales were small to moderate
(r = .02–.14), with the exception of the IC
and II scales that were strongly associated
(r = .52), the SP with ER and FG scales that
were strongly associated (r = .56 and .55,
respectively), and the ER and FG scales that
were moderately associated (r = .30). Items
that comprise each subscale as well as factor
loadings are presented in the Appendix.
Preliminary Analyses
We examined the distribution of each
variable to identify variables that were unac-
9
ceptably skewed or kurtotic (see Table 1 for
descriptive statistics); no variables were identified as showing unacceptable departures
from normality (Kline, 1998). We also examined the shared variance between independent variables of interest (Table 2); most
variables shared small or medium variance
(r < .24 and < .37, respectively), with the
exception of negative affective intensity with
emotion dysregulation (r = .47) and reactivity (r = .53), and, among social functioning
variables, social problem solving, and total
interpersonal problems (r = .44). Nevertheless, most individual subscales of the IIP and
SPSI were moderately correlated (r = .01–
.34) with the exception of negative problem
orientation and vindictive/self-centered
interpersonal style (r = .38).
Characteristics of NSSI Behavior in the
Present Sample
In this sample, 98.2% of participants
endorsed having engaged in cutting at some
point in their lives, and 79.8% of participants
reported that cutting was their most frequent
method of self-injury. Other methods
endorsed included, for example, hitting self
(63.6%), scratching the skin until blood was
drawn (64.9%), burning (47.3%), and banging
one’s head against a wall (42.4%). In terms of
average frequency of NSSI over the lifetime,
13.8% of participants reported engaging in
NSSI daily or more than once per day, 25.6%
reported engaging in NSSI three to six times
per week, 17.5% reported engaging in NSSI
one to three times per week, 24.4% reported
engaging in NSSI two to three times per
month, and 18.8% reported engaging in NSSI
once a month or less often. NSSI over the past
3 months was less frequent, with 6.2% of participants reporting engaging in NSSI daily or
more frequently, 14.3% reporting engaging
in NSSI three to six times per week, 19.9%
reporting engaging in NSSI one to two times
per week, 20.5% reporting engaging in NSSI
two to three times per month, 19.3% reported
engaging in NSSI once a month or less often,
and 19.9% reporting that they had not
engaged in NSSI in the past 3 months.
10
FUNCTIONS OF NSSI, EMOTIONAL AND SOCIAL FUNCTIONING
TABLE 1
Descriptive Statistics
Minimum Maximum Mean
ER functions
FG functions
SP functions
IC functions
II functions
AIM positive intensity
AIM negative intensity
AIM negative reactivity
ERQ suppression
ERQ reappraisal
DERS total
SPSI total
IIP total
9.00
4.00
5.00
3.00
5.00
15.00
15.00
6.00
1.00
1.00
76.00
1.03
0.41
45.00
20.00
15.00
15.00
25.00
83.00
36.00
36.00
6.75
6.50
163.00
15.56
3.16
33.18
12.35
11.12
6.17
4.80
49.94
25.77
24.12
4.48
3.73
121.77
7.83
1.77
SD Skewness Skewness SE Kurtosis Kurtosis SE
6.80
4.46
2.19
2.88
2.60
14.55
4.85
5.55
1.21
1.25
20.15
3.28
0.45
)0.49
)0.35
)0.37
0.75
1.73
0.31
)0.16
)0.35
)0.41
)0.20
)0.11
0.08
0.05
0.19
0.19
0.19
0.19
0.19
0.19
0.19
0.19
0.19
0.19
0.19
0.19
0.19
0.20
)0.87
0.01
0.09
2.56
)0.41
)0.55
0.21
)0.11
)0.54
)0.53
)0.52
0.54
0.38
0.38
0.38
0.38
0.38
0.38
0.38
0.38
0.38
0.38
0.38
0.38
0.38
SD, standard deviation; SE, standard error; ER, Emotion Relief; FG, Feeling Generation; SP,
Self-Punishment; IC, Interpersonal Communication; II, Interpersonal Influence; AIM, Affect Intensity
Measure; ERQ, Emotion Regulation Questionnaire; DERS, Difficulties in Emotion Regulation Scale;
SPSI, Social Problem Solving Inventory; IIP, Inventory of Interpersonal Problems.
TABLE 2
Correlations Between Emotional and Social Functioning Variables
DERS
total
AIM
AIM
AIM
ERQ
ERQ
positive negative negative
suppress reappraise intensity intensity reactivity
DERS total
1
ERQ suppress
0.14
1
ERQ reappraise
)0.24*** 0.14
AIM positive intensity
0.03
)0.23***
AIM negative intensity
0.47*** )0.08
AIM negative reactivity 0.20** )0.11
IIP total
0.53*** 0.23***
SPSI total
)0.50*** )0.13
1
0.26***
)0.13
0.10
)0.03
0.37***
1
0.36***
0.30***
0.10
0.08
IIP
total
1
0.54***
1
0.43***
0.34***
1
)0.26*** )0.07
)0.44***
SPSI
total
1
DERS, Difficulties in Emotion Regulation Scale; ERQ, Emotion Regulation Questionnaire; AIM,
Affect Intensity Measure; IIP, Inventory of Interpersonal Problems; SPSI, Social Problem Solving
Inventory.
*p < .05, **p < .05, ***p < .005.
In terms of endorsement of each functional category, 99.4% of participants
endorsed ER functions (i.e., endorsed ER
functions at nonzero level), 92.0% endorsed
some FG functions, 100% endorsed some SP
functions, 85% endorsed some IC functions,
and 50.6% endorsed some II functions.
Excluding SP functions, which all participants endorsed, many participants (42%)
endorsed some items from all four other func-
tional categories, whereas 40.7% of participants endorsed items from three functional
categories, suggesting that most participants
reported that NSSI served multiple functions.
Examination of Potential Covariates
We examined whether functions of
NSSI were significantly associated with age
and frequency of NSSI. None of the five
DERS, Difficulties in Emotion Regulation Scale; AIM, Affect Intensity Measure; ERQ, Emotion Regulation Questionnaire; ER, Emotion Relief;
FG, Feeling Generation; SP, Self-Punishment; II, Interpersonal Influence; IC, Interpersonal Communication; NSSI, Nonsuicidal Self-injury.
*p < .05, **p < .01, ***p < .005.
0.23***
0.17*
0.32***
)0.32***
)0.29***
0.14
0.14
0.02
0.04
0.03
0.23***
0.12
0.21**
0.18*
0.10
0.35***
0.14
0.35***
0.18*
0.01
0.21**
0.31***
0.12
0.03
)0.01
0.09
0.20*
0.02
)0.03
0.00
0.36***
0.11
0.29***
0.12
0.05
0.27***
0.19*
0.28***
0.11
0.00
0.21**
0.08
0.19*
0.13
0.04
0.28***
0.12
0.32***
)0.01
0.00
0.41***
0.28***
0.35***
0.10
0.03
ER functions
FG functions
SP functions
II functions
IC functions
DERS:
clarity
Zero-Order Correlations Between Functions of NSSI and Emotional Functioning Variables
Zero-order correlations between the
five functions and emotional functioning
variables are presented in Table 3. The set of
emotional functioning variables that were significant at the zero-order level (based on Bonferroni-corrected p values) entered into the
hierarchical regression accounted for 24.6%
of the variance in ER functions, 13.5% of the
variance in FG functions, 25.7% of the variance in SP functions, 8.0% of the variance in
IC functions, and 10.3% of the variance in II
functions. Results of the hierarchical regressions are presented in Table 4.
Hypothesis 1a. We expected ER functions to be associated with greater affective
intensity and reactivity, greater use of expressive suppression, and greater difficulty in
emotion regulation. The pattern of correlations among these variables was largely consistent with this hypothesis. At the zero-order
level, affective intensity and reactivity were
associated with ER functions (r = .35,
p < .001 and r = .23, p = .004, respectively),
as was expressive suppression (r = .23,
p = .004) and difficulties in emotion regulation (r = .41, p < .001). In the regression predicting ER functions, the first three blocks
(frequency of NSSI, affective intensity and
reactivity, and expressive suppression) each
uniquely accounted for a significant proportion of variance in the model (frequency of
NSSI: b = .24, p = .003; negative affective
intensity: b = .29, p = .001; affective reactivity: b = .07, p = .45; expressive suppression:
b = .20, p = .008). Among the difficulties in
emotion regulation (DERS) scales, only lim-
TABLE 3
Analyses Examining Emotional Functioning Variables
DERS:
DERS:
DERS:
DERS:
DERS:
DERS:
total
nonacceptance goals impulsivity strategy awareness
functions were associated with age (r = .01 to
).07; all p ‡ .39). ER, FG, and SP functions
were positively associated with lifetime frequency of NSSI (r = .23, .20, .21, respectively; all p < .05); subsequent analyses
involving these variables included lifetime
frequency as a covariate. II and IC functions
were not associated with lifetime frequency
of NSSI (r = ).02, p = .83 and r = .05,
p = .16, respectively).
0.00
0.01
0.01
)0.03
0.06
11
AIM:
AIM:
ERQ:
ERQ:
negative AIM: negative positive
intense suppress reappraise
intense
reactivity
TURNER ET AL.
12
FUNCTIONS OF NSSI, EMOTIONAL AND SOCIAL FUNCTIONING
TABLE 4
Hierarchical Regression
Block of predictors
ER
R2 change
1: Frequency of NSSI
2: Affective traits
.06**
.11**
3: Emotion regulation strategy
4: Difficulties in emotion regulation
.04**
.04
FG
1: Frequency of NSSI
2: Difficulties in emotion regulation
.04*
.10**
SP
1: Frequency of NSSI
2: Affective traits
3: Emotion regulation strategy
4: Difficulties in emotion regulation
.04*
.10**
.09**
.02
II
1: Frequency of NSSI
2: Emotion regulation strategy
1: Frequency of NSSI
2: Emotion regulation strategy
IC
<.01
.10**
<.01
.08**
Subscale
Frequency of NSSI
Negative intensity
Affective reactivity
Suppression
Nonacceptance
Impulsivity
Strategies
Frequency of NSSI
Impulsivity
Clarity
Frequency of NSSI
Negative intensity
Suppression
Nonacceptance
Impulsivity
Strategies
Frequency of NSSI
Suppression
Frequency of NSSI
Suppression
b
t
p
.24
.33
.07
.20
.01
.01
.22
.19
.15
.25
.20
.32
.30
.12
.07
.04
.07
).32
).08
).28
3.06
4.44
0.76
2.69
0.09
0.14
2.21
)2.46
1.98
3.22
2.57
4.28
4.21
1.322
0.72
0.40
)0.85
)4.17
0.99
)3.52
.003
<.001
.447
.008
.923
.888
.029
.015
.050
.002
.011
<.001
<.001
.19
.471
.692
.396
< .001
.323
.001
ER, Emotion Relief; FG, Feeling Generation; SP, Self-Punishment; II, Interpersonal Influence;
IC, Interpersonal Communication; NSSI, Nonsuicidal Self-injury.
*p < .05, **p < .01.
ited access to emotion regulation strategies
was uniquely associated with ER functions
(b = .22, p = .03).
Hypothesis 1b. We expected FG functions to be associated with greater affective
reactivity, greater use of expressive suppression, and greater difficulties with emotion
regulation. At the zero-order level, affective
reactivity was not associated with FG functions (r = .12, p = .14) nor was expressive suppression (r = .20, p = .01). Difficulties in
emotion regulation were positively associated
with FG functions (r = .31, p < .001), particularly impulsivity (r = .24, p = .003) and a lack
of emotional clarity (r = .30, p < .001). In the
regression predicting FG functions, these two
DERS scales explained significant variance
beyond NSSI frequency (R2 change = .10, p <
.001). Only lack of emotional clarity explained
unique variance in FG functions (b = .25,
p = .002), although impulsivity when distressed
was nearly significant (b = .15, p = .05).
Hypothesis 1c. We expected SP functions to be associated with more intense
affect and greater difficulties with emotion
regulation, especially nonacceptance of emotions. Zero-order correlations supported this
hypothesis; SP functions were positively
associated with negative affective intensity
(r = .35, p < .001), expressive suppression
(r = .32, p < .001), and difficulty regulating
emotions (r = .35, p < .001), particularly
nonacceptance
of
emotions
(r = .32,
p < .001), impulsivity (r = .28, p < .001), and
limited emotion regulation strategies
(r = .29, p < .001). In the regression predicting SP functions, the first three blocks (frequency of NSSI, affective intensity, and
expressive suppression) each uniquely
accounted for a significant proportion of variance in the model (frequency of NSSI:
b = .20, p = .011; negative affective intensity:
b = .32, p < .001; expressive suppression: b =
.30, p < .001). None of the DERS subscales
TURNER ET AL.
contributed unique variance to the model
nor did the combination of the scales
account for unique variance when added in
the fourth block (R2 change = .02, p = .23).
Hypothesis 1d. We expected II and IC
functions of NSSI to be associated with
greater affective reactivity rather than intensity. Zero-order correlations did not support
this hypothesis Neither II functions (r = .12,
p = .12) nor IC functions (r = .10, p = .21)
were associated with affective reactivity nor
was either interpersonal function associated
with affective intensity (IC: r = .01, p = .86,
II: r = .18, p = .02). Consistent with hypothesis 1c, IC and II functions were negatively
associated with expressive suppression
(r = ).29, p < .001; r = ).32, p < .001).
Given that only expressive suppression was
significantly associated with II and IC functions, regressions revealed the same pattern
of associations as zero-order correlations (IC
functions b = ).29, p < .001; II functions
b = ).32, p < .001).2
Analyses Examining Social Functioning
Variables
Zero-order correlations with social
functioning variables are presented in
Table 5. Only a domineering interpersonal
style was significantly associated with II functions at the zero-order level using the Bonferroni-corrected cut-off (r = .32, p < .003),
although an intrusive or needy style (r = .23,
p = .004), a negative orientation to social
problems (r = .18, p = .02), and an impulsive
or careless social problem-solving style
(r = .20, p = .01) were associated with II functions using less stringent cut-offs. By contrast,
none of the social functioning variables were
2
We repeated these regression analyses
controlling for current symptoms of depression as
assessed by the Beck Depression Inventory II
(Beck, Steer, & Brown, 1996), lifetime frequency of
NSSI, and frequency of NSSI in the past 3 months.
The pattern of findings did not change, and each of
the emotional functioning predictors that was significant in the original regression remained significant, with the exception of expressive suppression
in the regression predicting ER functions, which
was no longer significant (b = .14, p=.086).
13
significantly associated with IC functions,
although an intrusive or needy style
approached significance (r = .20, p = .01).
Given this unexpected pattern of findings, we divided participants into two
groups: those who had engaged in NSSI at
least once per week over the past 3 months
(n = 96) and those who had engaged in NSSI
less than once per week (n = 65) to examine
whether associations between interpersonal
functions of NSSI and social functioning differed by group. Repeating the zero-order
correlations, we found that among individuals who engaged in more frequent NSSI,
domineering or controlling and intrusive or
needy interpersonal styles were significantly
associated with II functions (r = .47, p < .001
and r = .42, p < .001, respectively), whereas a
vindictive/self-centered style was associated
with IC functions (r = .41, p < .001) and
cold/distant styles approached significance
(r = .28, p = .007). Among individuals with
less frequent NSSI, none of the social functioning variables were associated with II or
IC functions. As such, we conducted regression analyses using only the individuals who
self-injured frequently.
Hypothesis 2a. We expected II functions to be associated with domineering and
vindictive interpersonal styles. Among individuals with frequent NSSI, problematic
interpersonal styles accounted for significant
variance in II functions beyond NSSI frequency
(R2 change = .26, p < .001). Both domineering/controlling (b = .34, p = .002) and intrusive/needy styles (b = .25, p = .02) accounted
for unique variance in II functions (see
Table 6).
Hypothesis 2b. We expected that IC
functions would be associated with a nonassertive interpersonal style. Given that only a
vindictive/self-centered style was associated
with IC functions at the zero-order level, a
hierarchical regression was unnecessary.
DISCUSSION
Findings from this study highlight
some of the specific affective traits, emotion
SPSI, Social Problem Solving Inventory; PPO, Positive Problem Orientation; NPO, Negative Problem Orientation; PDF, Problem Definition and
Formulation; GAS, Generation of Alternative Solutions; DM, Decision Making; SIV, Solution Implementation Verification; ICS, Impulsivity/Careless Style;
AS, Avoidance Style; RPS, Rational Problem Solving; IIP, Inventory of Interpersonal Problems; PA, Domineering/Controlling; BC, Vindictive/Self-Centered; DE, Cold/Distant; FG, Socially Inhibited; HI; Nonassertive/Passive; JK, Overly Accommodating/Exploitable; LM, Self-Sacrificing/Overly Nurturing;
NO, Intrusive/Needy; ER, Emotion Relief; FG, Feeling Generation; SP, Self-Punishment; II, Interpersonal Influence; IC, Interpersonal Communication;
NSSI, Nonsuicidal Self-injury.
*p < .05, **p < .01, ***p < .005.
ER functions )0.27*** )0.12 0.33*** )0.09 )0.05 )0.01 )0.01 0.25*** 0.25*** )0.04
FG functions )0.17* )0.06 0.16* )0.11 0.02 )0.04 0.01 0.22** 0.14 )0.04
SP functions )0.17* )0.06 0.26*** )0.07 )0.01 )0.02 0.09 0.16* 0.14 )0.01
II functions )0.16
0.01 0.18* )0.09 )0.07 )0.09 )0.09 0.20* 0.12 )0.08
IC functions )0.08
0.01 0.08
0.00 )0.05 )0.10 )0.10 0.10 0.06 )0.05
LM
JK
HI
FG
DE
BC
PA
RPS IIP total
AS
ICS
PPO NPO PDF GAS DM SIV
SPSI
Zero-Order Correlations Between NSSI Functions and Social Functioning Variables
TABLE 5
0.34*** )0.02
0.25*** 0.23** 0.33*** 0.21** 0.21** 0.23** 0.01
0.30*** 0.18*
0.29*** 0.30*** 0.16* 0.02 0.13 0.22** 0.08
0.29*** 0.10
0.33*** 0.27*** 0.18* 0.06 0.15 0.16 0.03
0.14
0.32*** 0.13 )0.09 )0.08 0.05 0.08 0.08 0.23***
0.01
0.09 )0.02 )0.16* )0.12 0.02 0.10 0.03 0.15
FUNCTIONS OF NSSI, EMOTIONAL AND SOCIAL FUNCTIONING
NO
14
regulation deficits, and interpersonal styles
that may render a person more likely to
engage in NSSI to achieve specific goals.
Overall, our findings supported the validity
of existing theoretical models proposing both
self-regulation (ER, FG, and SP) and social
functions (IC and II) for NSSI by demonstrating that the functions of NSSI are associated with a theoretically expected manner
with unique emotional vulnerabilities and
interpersonal styles. In highlighting the emotional and social vulnerabilities that contribute to engaging in NSSI for certain
purposes, our findings suggest avenues for
clinical intervention.
Beyond supporting existing conceptualizations and treatments for NSSI, examining the specific vulnerabilities associated
with the functions of NSSI may help us better understand why some individuals engage
in this behavior. This study expanded previous research by examining how functions of
NSSI are associated with specific affective
traits, emotion regulation skills, interpersonal styles, and social problem-solving
skills. Consistent with previous research, our
findings demonstrate that individuals report
engaging in NSSI in the service of multiple
functions (Kleindienst et al., 2008; Nock et
al., 2009). In terms of specific functions of
NSSI, ER functions were associated with
intense negative affect and expressive
suppression. Findings from several studies
have indicated that the suppression of
thoughts and emotions often results in more
intense emotions and more emotional problems over the long term (Craske, Miller,
Rotunda, & Barlow, 1990; Gross & Levenson, 1997; Lynch, Robins, Morse, & Krause,
2001); thus, expressive suppression likely
compounds an individual’s struggle to relieve
aversive emotions over the long term. Further, ER functions were associated with a
number of difficulties in emotion regulation,
particularly limited emotion regulation strategies. Together, these vulnerabilities may
create a cycle whereby the individual seeks
relief from increasingly overwhelming emotions but is unable to effectively express or
regulate these emotions and thus becomes
TURNER ET AL.
15
TABLE 6
Hierarchical Regression
II
Block of predictors
R2 change
Subscale
b
t
p
1: Frequency of NSSI
2: Interpersonal problems
.01
.26**
Frequency of NSSI
Domineering/controlling
Intrusive/needy
).07
.34
.25
)0.69
3.18
2.384
.493
.002
.019
NSSI, Nonsuicidal Self-injury.
more likely to engage in maladaptive strategies such as NSSI to regulate emotions.
Consistent with previous research, this pattern may be exacerbated by symptoms of
depression and hopelessness. Interventions
to reduce NSSI enacted for ER functions
should focus on better tolerating, regulating,
and expressing emotions.
In contrast to ER functions, FG functions of NSSI were uniquely associated with
a lack of emotional clarity. Not surprisingly,
individuals who experience their emotions as
confusing or unclear may be more likely to
resort to behaviors such as NSSI to obtain
desired emotional states. Further, this evidence suggests that individuals who report
that they use NSSI to relieve feeling numb
or feeling ‘‘nothing’’ may find this state profoundly aversive. Thus, FG functions may
reflect attempts to reduce intense but poorly
understood emotional arousal, consistent
with problems in emotional clarity. At the
zero-order level, FG functions were also
associated with difficulty inhibiting impulsive
behavior when distressed. The combination
of confusion regarding one’s emotional state
and heightened impulsivity likely increases
the likelihood that an individual would resort
to a maladaptive behavior such as NSSI to
regulate their internal state. Interventions to
increase emotional awareness may be helpful
in reducing NSSI enacted for FG purposes.
There was considerable similarity in
the pattern of associations between the emotional functioning variables and ER functions
as well as SP functions. In both cases, at the
zero-order level, the functions were significantly associated with greater affective intensity, expressive suppression, and difficulty
regulating emotions. In the regression predicting SP functions, difficulties in emotion
regulation did not account for variance in the
model beyond the other emotion variables,
whereas in the model predicting ER functions they did; otherwise the pattern of findings was largely consistent for the two
functions. These similarities suggest that
self-punishment may be a special case of ER
functions, wherein the individuals seeks relief
from aversive self-focused emotions such as
shame and guilt rather than more general
emotions such as sadness or anxiety. As with
ER functions, interventions to reduce NSSI
engaged in for SP purposes should focus on
increasing tolerance and expression of
intense emotions.
IC functions were associated with a
lack of expressive suppression and, among
those who self-injure once a week or more
frequently, a vindictive or self-centered
interpersonal style. Consistent with the idea
that NSSI is sometimes enacted to communicate distress, IC functions were negatively
associated with expressive suppression, suggesting they are related to a higher willingness to outwardly exhibit or communicate
distress. If these tendencies are further
understood in the context of a vindictive or
self-centered interpersonal style, which
reflects greater need for affiliation and attention from others but low warmth and empathy, it is plausible that NSSI would become a
viable option for communicating with others
(Nock, 2008). These findings suggest that
increasing effective expression of one’s emotions, promoting empathy, and enhancing
effective communication skills would help
reduce NSSI enacted for IC functions.
16
FUNCTIONS OF NSSI, EMOTIONAL AND SOCIAL FUNCTIONING
Similar to communication functions,
II functions were associated with a lack of
expressive suppression, and, among those
who self-injure frequently, a domineering or
controlling interpersonal style and an intrusive or needy interpersonal style. This combination indicates willingness to express
one’s distress and a high need for affiliation
as well as a willingness and desire to exert
control over one’s environment. This combination may make it more likely that the individual seeks not only to express his or her
distress through their behavior but also seeks
to modify the emotions or behavior of others. These findings suggest that increasing
effective expression of one’s emotions and
promoting effective interpersonal skills
would help reduce NSSI enacted for II functions.
Taken together, these findings suggest
that interventions aimed at reducing NSSI
must consider a variety of targets, such as
regulation of uncomfortable or intense emotions, increasing effectiveness of interpersonal communication, and strategies to
increase emotional clarity and expression.
Indeed, existing treatments address many of
these goals (e.g., Dialectical Behavior Therapy, Linehan, 1993; Manual Assisted Cognitive Therapy, Evans et al., 1999); however,
the treatment data on the reduction in NSSI
suggest that there is considerable room for
refinement and improvement in interventions (Evans et al., 1999; Tyrer et al., 2003).
This research may help clinicians prioritize
treatment targets and intervention strategies
by underscoring the specific emotional and
social deficits that are associated with
engagement in NSSI to achieve particular
ends.
Limitations and Future Directions
Several limitations of this study warrant discussion. First, although the social
and emotional vulnerabilities accounted for
significant variance in NSSI functions, it
should be noted that the set of independent
variables generally accounted for a small
amount of variance in NSSI functions.
Thus, future research incorporating a
broader set of predictors or novel methods
of assessment (such as behavioral or experimental assessment of emotional and social
functioning) can improve our understanding
of how these variables are related. A second
limitation arises because this sample was
recruited from online forums. Although the
use of online recruitment allowed us to
gather a large and more diverse sample than
would have been possible had we recruited
exclusively from the local community, our
participants may be younger, more affluent,
more extraverted, and more likely to seek
support for their NSSI compared with individuals who do not use such forums.
Although many participants had sought psychological treatment in the past year, replication in a clinical sample is needed before
these results can be generalized to psychiatric samples. Further, participants in this
study likely exhibit more clinically severe
NSSI than would be seen in nontreatmentseeking community samples (e.g., most participants used methods of NSSI that are
likely to result in tissue damage such as cutting; most reported engaging in NSSI at
least a few times a week over their lifetime;
Brausch & Gutierrez, 2010; Williams &
Hasking, 2010). It is possible that the emotional and social vulnerabilities documented in
this study may be less salient among individuals
who engage in NSSI infrequently or who
use less damaging methods of NSSI. Thus,
examination of these relationships in other
samples would bolster confidence in these
results and in existing theoretical models of
NSSI.
Other limitations arise from our conceptualization and measurement of the functions of NSSI. First, owing to a lack of a
cross-validation sample, we were only able to
perform an EFA to assess the functionrelated constructs of interest. Research confirming the factor structure and exploring
psychometric properties of the QNSSI in
other samples would support the use of this
measure in future work. Second, we chose to
focus on five functions that were identified
by the factor analysis and have previously
TURNER ET AL.
been supported in the literature; however,
the association of emotional and social functioning with other important functions of
NSSI, such as anti-suicide and assertion of
interpersonal boundaries (Klonsky, 2007),
should be examined in future research.
Third, we relied on self-report methods to
explore motivations for engagement in
NSSI. Although helpful for understanding
an individual’s perceptions regarding the
purpose of their behavior, this approach is
limited in that people may not be aware of
the internal and external contingencies that
actually maintain their behavior, and/or they
might provide biased or socially desirable
responses. Future research assessing motivations or consequences closer in time to the
actual act of NSSI, possibly using ecological
momentary assessment methods (e.g., Nock
et al., 2009) or examining implicit associations or motivations (e.g., Nock & Banaji,
2007), might further clarify emotional and
social factors associated with functions of
NSSI.
Along similar lines, the term function is
defined in a variety of ways in the literature,
ranging from the purpose or desired effect of
the behavior (Brown et al., 2002; Kumar et
al., 2004; Laye-Gindhu & Schonert-Reichl,
2005) to motivations underlying NSSI
(Schnyder et al., 1999), to consequences that
17
serve to reinforce or punish the behavior
(Chapman & Dixon-Gordon, 2007; Chapman et al., 2006; Haines et al., 1995). For
this study, we defined function as the purpose for which the individual engaged in the
behavior. Studies examining actual or perceived consequences of NSSI, rather than
stated purposes, would round out the picture
and may highlight additional emotional and
social contingencies that reinforce NSSI.
Finally, although we were interested in
examining vulnerability factors that predict
each function of NSSI, this study employed a
cross-sectional design; conclusions regarding
the prediction of engagement in NSSI for
various functions over time require longitudinal research. Although cross-sectional
research often serves as a valuable first step
in investigating relationships of interest, an
important future direction would involve
longitudinal studies examining the possible
interplay of NSSI and the emotional and
social difficulties examined in this study over
time. Additionally, research on factors associated with changes in functions of NSSI
over time or throughout treatment might
illuminate how and when to use particular
intervention strategies to replace NSSI with
effective coping or behaviors that serve similar functions.
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Manuscript Received: May 26, 2011
Revision Accepted: October 21, 2011
APPENDIX: QNSSI SUBSCALES FACTOR LOADINGS
Emotion relief
To bring my mood to a comfortable level (0.48)
To stop bad feelings (0.61)
To get away or escape from thoughts and memories, my feelings, other people, or myself (0.55)
To distract yourself from other problems (0.67)
To relieve feelings of aloneness, emptiness, or isolation (0.71)
To obtain relief from a terrible state of mind (0.67)
To stop feeling sad (0.78)
To prevent being hurt in a worse way (0.43)
To relieve anxiety (0.43)
Feeling generation
To feel my body again (0.78)
To feel something, even if it was pain (0.86)
To stop feeling numb or dead (0.84)
To regain a sense of reality (0.46)
Interpersonal communication
To communicate or let others know how desperate I am (0.93)
Others to see how badly I am doing (0.66)
To get help (0.49)
Interpersonal influence
To get other people to act differently or change (0.82)
To get back at or hurt someone (0.85)
To demonstrate to others how wrong they are/were (0.66)
Self-punishment
To decrease uncomfortable feelings (guilt, rage, etc.) (0.55)
To stop feelings of self-hatred or shame (0.64)
To punish myself (0.70)