Non-suicidal self-injury (NSSI) is the direct, purposeful self-infliction of injury, which results in tissue damage, is performed without conscious suicidal intent and through methods that are not socially sanctioned (Nixon & Heath, 2009). The phenomenon of self-injurious behaviours is alarming, especially among adolescents and young adults (Muehlenkamp, 2005). In fact, it is estimated that lifetime prevalence of NSSI in young adults within the general population is around 12% to 38% (for reviews, see Heath, Schaub, Holly, & Nixon, 2009; Jacobson & Gould, 2007; Rodham & Hawton, 2009). While this proportion declines when assessing recent NSSI (i.e., usually performed in the past six months or in the past year), the numbers are still disturbing with 2.5% to 12.5% of young adults reporting current NSSI (for reviews, see Heath et al., 2009; Jacobson & Gould, 2007; Rodham & Hawton, 2009). The goal of this thesis is to investigate the associations between romantic relationships and NSSI in young adults and to address two major limitations that emerge from the literature, namely: a) several theoretical hypotheses have yet to be validated despite considerable advances in the scientific study of NSSI; and b) with the exception of one study, the few studies available relating romantic relationships and NSSI solely focused on the individual level of analysis instead of including both partners in the model. This goal will be addressed through three articles, each targeting specific objectives. For the sake of methodological rigor and for adequate evaluation of the constructs under study, the purpose of the first study was to validate the factorial structure of the English version of the Dyadic Coping Inventory (DCI; Bodenmann, 2008). A confirmatory factor analysis (CFA) corroborated the measurement theory of the DCI by revealing the presence of five coping factors (i.e., stress communication, supportive dyadic coping, delegated dyadic coping, negative dyadic coping, common dyadic coping) and two target factors (i.e., one’s own dyadic coping and partner’s dyadic coping). The English DCI also demonstrated good internal reliability and yielded preliminary evidence of concurrent validity. All together, these findings lead to the conclusion that the English DCI is an accurate and reliable measure of dyadic coping, and that researchers can use the English DCI confidently in their research to evaluate dyadic coping processes. The established factorial structure of the English DCI was then used in subsequent studies of this thesis. The purpose of the second study was to investigate direct and indirect associations between insecure romantic attachment, difficulties in emotion regulation and common dyadic coping strategies, and endorsement of NSSI behaviours. From an empirical standpoint, this study is the first to explore these specific relationships in one comprehensive model, targeting both interpersonal and intrapersonal strategies to deal with stressful experiences and the role it might have on one’s NSSI behaviours. Overall, the results revealed that difficulties in emotion regulation mediated the relationships between romantic attachment insecurity (i.e., attachment anxiety and attachment avoidance) and NSSI, whereas no such effects were found for common dyadic coping strategies. Findings from this study suggest that intrapersonal strategies (i.e., emotion regulation) might be more influential on one’s NSSI behaviours than behavioural strategies (i.e., common dyadic coping). This study also offers a first step towards the understanding of the romantic relational context of individuals struggling with NSSI behaviours. The next step remains to explore the couple as the unit of analysis rather than focusing on only one member of the relationship, giving way to the third study of this thesis. The primary aim of the third study was to generate a general portrait of young women’s romantic relationship functioning, distinguishing women who recently self-injured from those who have never self-injured. This study was designed to permit the exploration of not only the individual-level effects, but also potential effects from the romantic partner. Through a series of nonparametric Mann-Whitney U tests, results revealed that women who engage in NSSI behaviours are more likely to report subjective distress in the form of attachment anxiety and distrust compared to women who do not engage in NSSI behaviours. They also reported good, but slightly lower levels of, relationship satisfaction and adaptive dyadic coping strategies compared to women who have never engaged in NSSI. Findings also showed that partners of women who engage in NSSI behaviour reported more attachment anxiety than partners of women who do not engage in NSSI behaviours. The women and their partner’s reports about their romantic relationship experiences provide unique insight into the similarities and differences of individuals who self-injure and those who do not. Furthermore, a cursory exploration of the partners’ NSSI behaviours revealed that nearly one-third of the partners in a relationship with women who self-injured also reported having recently engaged in NSSI behaviours. These findings add some depth to the understanding of the relational context of those who are struggling with NSSI and provide future directions in research.

The purpose of this study is to describe how, and if, discourses about self-harm in young people has been changed from the late 90-s until today. We chose to do this by studying films where the content of self-harm is a big factor. The study is built on a narrative research, we did however analyze it as a discourse method. The issues we have concentrated on are: Is there a significant quality that describes an individual who cut themselves? How can this phenomenon be seen from a gender point of view? Is there a specific group of people who is labeled as a person who cut themselves from the public? The result from this study show us that self-injury, from symptoms of a (bad) mental state, is a strong discourse where the views from the society lets it become more acceptable. However, there are other reasons for self-harm that is developed by the social difficulties, which is illustrated in these films. Norms and beliefs around what is male or female have not been changed from the beginning of the time period we have studied until today. Self-mutilation is still seen as a typical female thing – a woman problem. The persons who are pointed out as cutting themselves are typical white, young, dramatic girls. These girls also exhibit depth - and shame for the problem and its environment.

Members of 26 MySpace social groups for self-injury (SI) provided data for this study investigating knowledge of SI, friends’ perceptions of SI, and the impact of online activity on SI. This study proposes that people who have belonged to these online SI groups for longer periods have higher levels of SI knowledge than those group members who have recently joined. In addition, the study proposes that individuals who self-injure have higher levels of SI knowledge than professionals who work with individuals who self-injure. An additional purpose of this study is to explore information regarding the reasons why people belong to online SI groups, the outcomes of participating in them, and their perceptions of their online peers’ and face-to-face peers’ attitudes regarding SI. A convenience sample of 101 members solicited from SI social groups on MySpace completed the survey, which consisted of five sections including the following: demographics, experiences with SI, knowledge of SI, activities related to SI in MySpace groups, and perceptions of online and face-to-face peers’ attitudes regarding SI. The knowledge section of the survey contains a 20 item measure previously used by Jeffrey and Warm (2002). A knowledge score was created based on participants responses to these 20 items. This score was used in the analysis of both hypotheses one and two. Results indicate that participants have a good understanding of SI, based on their mean knowledge score. In addition, results reveal that the current sample’s mean SI knowledge level is higher than are four of the seven groups' mean knowledge scores. Length of membership on online SI groups is not significantly greater for individuals who score higher on the knowledge of SI measure as assessed through independent t tests. Descriptive information indicates that participants perceive their online friends to react more positively to their self-injurious behaviors than they do their face-to-face friends. In addition, the sample does not indicate that participation in online SI groups has an impact on the frequency of their self-injurious behaviors, which is consistent with prior research (Murray & Fox, 2006). Limitations discussed include sample size and solicitation, survey length, and the lack of a thorough assessment of online activity.

En experimentell vinjettstudie genomfördes för att undersöka hur graden av em-pati för personer med ett självskadebeteende varierar beroende på bakomliggande orsak samt grad av kännedom om ämnet. I studien deltog 121 respondenter som fick besvara en av tre vinjetter: (a) självskadebeteende utan angiven orsak, (b) Självskadebeteende med orsak borderline personlighetsstörning eller (c) Självska-debeteende med orsak övergrepp. Studien visade att ett samband mellan empati och självskadebeteende utan orsak samt mellan empati och självskadebeteende med orsak borderline personlighetsstörning. Inget samband påvisades mellan em-pati och självskadebeteende med orsak övergrepp. Vidare framkom inga signifi-kanta skillnader mellan grupperna i empatigrad, vilket kan ha att göra med att självskadebeteende som enskild variabel var tillräcklig för att generera ett visst mått av empati. Empatimedelvärdet för någon som skär sig låg strax under media-nen på Batsons empatiskala vilket tyder på att medmänniskor känner en genom-snittlig grad av empati för någon som skär sig.

Nonsuicidal self-injury (NSSI) and eating disorder behaviours (EDB) may share a similar emotion dysregulation mechanism. This study examined the relations between repeated rumination episodes and emotions in NSSI and EDB within the context of the Emotional Cascades Model (Selby, Anestis, & Joiner, 2008), which suggests that ruminating on negative events increases the intensity of negative emotion; negative emotion prompts continued rumination, which further increases the intensity of the negative emotion. Individuals with a history of NSSI and/or EDB reported higher levels of negative emotions and lower levels of positive emotions, relative to individuals without a history of these behaviours. Similarly, a history of NSSI was associated with greater initial increases in negative emotions, and a history of EDB was associated with greater initial decreases in positive emotions, following rumination. While these results support the presence of emotion dysregulation in NSSI and EDBs, it only partially supports the emotional cascades model. / CIHR graduate award helped to fund this research.

Young adults who self-injure may prefer to disclose these experiences to peers versus professionals, however, past research has demonstrated that their responses are rated as less helpful compared to other recipients. To better understand this phenomenon, the current study sought to investigate NSSI disclosures from the point of view of the disclosure recipient. Given the relation between various interpersonal trait variables (e.g., receptiveness, responsiveness, agreeableness), relationship factors (friendship quality, duration), and intimate self-disclosures, aspects of particular individuals and relationships may also play a role in the context of peer-to-peer NSSI disclosures and how effective these disclosure responses may be. An online battery of questionnaires was administered to examine these research questions in a population of 230 university students (178 females, M age = 18.38). 107 participants reported receiving a NSSI disclosure from a friend. Having a history of NSSI, lower social support, and greater perceived relative power were found to significantly predict receiving a NSSI disclosure from a friend and receptiveness and social support were found to significantly predict the recipients’ degree of helpful responding to the NSSI disclosure. Findings illuminate the important role of friends and of the friendship itself in facilitating the help-seeking process and promoting NSSI cessation. Research directions and implications are discussed.

Deliberate self-harm (DSH) is a major health concern, especially for high-risk populations such as incarcerated youth. DSH refers to socially unacceptable, deliberate behaviour that causes harm to the body regardless of intent to die. There is limited research concerning prevalence rates as well as risk and protective factors for high-risk, adolescent groups. Participants were recruited from a correctional facility for youth aged 12-18. Male (n = 36) and female (n = 51) incarcerated adolescents (N = 87; mean age = 15.9) completed a survey that measured social-demographic characteristics, current depressed mood, lifetime alcohol and drug use, perceptions of social support (availability and satisfaction), approach-avoidance coping, problem-solving confidence, and DSH. The prevalence rates (81% lifetime, 74% annual, and 51% while incarcerated) for this mainly Aboriginal and Métis population were much higher than previous offender, community, and hospital findings. Youth reported much higher rates of DSH on a checklist than in response to a general question previously used in such research, suggesting that previously reported prevalence rates are likely grossly underestimated. Hypotheses regarding risk and protective factors were only partially supported. Depressed mood and drug use were positively, directly related to annual DSH frequency. Depressed mood proved to be a significant risk factor as well for incarcerated DSH. Overall, protective factors did not predict DSH well for this group of offenders. Only approach coping was inversely related to DSH frequency. Participants in this study reported very low levels of protective factors, which likely affected the outcome of statistical analyses. In general, youth reported high rates of risk factors and low rates of protective factors. Rates of DSH warranting medical attention increased with duration and frequency of such behaviour, as did actually receiving medical attention. Although 74% of offenders indicated that medical attention had been warranted at least once, only 50% actually received medical attention. Offenders were equally likely to receive medical attention whether they had engaged in DSH once or repetitively. It is likely that offenders prefer to keep their behaviour private, which affects how often they seek medical attention, even if they believe it is warranted. Recommendations are advanced for detecting and responding to DSH in incarcerated youth.

According to the policy on Inclusive Education, teachers are increasingly expected to play a community and pastoral role in order to, in this way, be able to measure up to the needs of learners who are experiencing barriers to learning (such as, for example, self-mutilation). This study was undertaken to determine what knowledge and skills teachers have at their disposal to identify self-mutilators in inclusive classrooms and to provide basic aid to these learners. By means of a literature study, self-mutilation was elucidated, and attention was paid to an explanation of what exactly self-mutilation involved, the forms of self-mutilation, the causes of self-mutilation, self-mutilation and related conditions, and the characteristics of the self-mutilator. Linked to this, the focus was on the extent to which the teacher is capable of identifying self-mutilators in inclusive classrooms and providing basic aid to them. Focus was also placed on the community and pastoral role of the teacher, the teacher’s experience of inclusive education, and the National Strategy with regard to the Screening, Identification, Assessment, and Support of learners who experience barriers to learning. A full description of various therapeutic approaches and aid programmes that can be undertaken with self-mutilators concluded the literature review. This literature review indicated a gap regarding the availability of training programmes for South-African teachers without training or background knowledge of Psychology, to assist them in identifying self-mutilators and providing basic aid to self-mutilators. Quantitative descriptive research was used to gather data from teachers by means of a questionnaire with open and closed items. In this particular study, 319 teachers were purposively and randomly chosen from 16 secondary schools (eight Ex Model C schools and eight Township schools) from Districts D2 and D12 in the Krugersdorp/Roodepoort area of the Gauteng Department of Education. On the one hand, the questionnaire determined teachers‟ knowledge and skills with regard to the nature of, reasons for and characteristics of self-mutilation in inclusive classrooms, and whether they possessed skills to provide basic aid to self-mutilators. On the other hand, it was also determined by means of open questions how the teachers become aware of self-mutilators, the type of training they received to provide basic aid to self-mutilators, what they viewed being the influence of self-mutilation on teaching and learning and on emotional and social development, their views of the pastoral role of the teacher as well as what their attitude/view was with regard to the possible implementation of a training programme to identify self-mutilators in inclusive classrooms and to provide basic aid to them. Furthermore, the open questions explored the availability of support structures to teachers to assist them in identifying self-mutilators and providing basic aid to these learners, as well as the opportunities that teachers create for learners to talk about their problems. Results indicated that the teachers who took part in the study did not have adequate knowledge and skills at their disposal regarding the identification of, and provision of basic aid to self-mutilators. They were however in favour of the implementation of a training programme that would enable them to identify self-mutilators and provide basic aid to them. On the basis of the data obtained through the questionnaire, and in accordance with the literature, a training programme was developed. In the absence of training programmes for the support of teachers in the identification of, and aid to self-mutilators in South African schools, this study makes a distinct contribution. / PhD, Educational Psychology, North-West University, Vaal Triangle Campus, 2012

Deliberate self-harm (DSH) is a major health concern, especially for high-risk populations such as incarcerated youth. DSH refers to socially unacceptable, deliberate behaviour that causes harm to the body regardless of intent to die. There is limited research concerning prevalence rates as well as risk and protective factors for high-risk, adolescent groups. Participants were recruited from a correctional facility for youth aged 12-18. Male (n = 36) and female (n = 51) incarcerated adolescents (N = 87; mean age = 15.9) completed a survey that measured social-demographic characteristics, current depressed mood, lifetime alcohol and drug use, perceptions of social support (availability and satisfaction), approach-avoidance coping, problem-solving confidence, and DSH. The prevalence rates (81% lifetime, 74% annual, and 51% while incarcerated) for this mainly Aboriginal and Métis population were much higher than previous offender, community, and hospital findings. Youth reported much higher rates of DSH on a checklist than in response to a general question previously used in such research, suggesting that previously reported prevalence rates are likely grossly underestimated. Hypotheses regarding risk and protective factors were only partially supported. Depressed mood and drug use were positively, directly related to annual DSH frequency. Depressed mood proved to be a significant risk factor as well for incarcerated DSH. Overall, protective factors did not predict DSH well for this group of offenders. Only approach coping was inversely related to DSH frequency. Participants in this study reported very low levels of protective factors, which likely affected the outcome of statistical analyses. In general, youth reported high rates of risk factors and low rates of protective factors. Rates of DSH warranting medical attention increased with duration and frequency of such behaviour, as did actually receiving medical attention. Although 74% of offenders indicated that medical attention had been warranted at least once, only 50% actually received medical attention. Offenders were equally likely to receive medical attention whether they had engaged in DSH once or repetitively. It is likely that offenders prefer to keep their behaviour private, which affects how often they seek medical attention, even if they believe it is warranted. Recommendations are advanced for detecting and responding to DSH in incarcerated youth.

Non-suicidal self-injury (NSSI), such as intentionally cutting, burning or hitting oneself, is a behavior with potentially detrimental consequences and empirical studies are necessary to gain knowledge of how to prevent NSSI in adolescents. The aims of this thesis were to investigate the prevalence, methods, characteristics and functions of NSSI in a large community sample of Swedish adolescents, and to examine the relationship between NSSI and adverse life events and trauma symptoms. All empirical studies had a cross-sectional design and were based on 3,097 adolescents in the county of Östergötland, aged 15-17 years, in their first year of high school. Participating school classes were selected through a randomization process and administered self-report questionnaires. In study I (n = 3,060) a single item NSSI question resulted in a prevalence rate of 17.2%, while 35.6% of adolescents reported having engaged in NSSI at least once during the past year when given a checklist. The most commonly reported type of NSSI in this sample was “bit yourself”, followed by “hit yourself on purpose”, “erased your skin” and “cut or carved on your skin”. Applying the proposed DSM-5 diagnostic criteria of NSSI resulted in a prevalence rate of 6.7%. Results in study II (n = 2,964) showed that after controlling for gender, parental occupation and living conditions, adolescents with no self-injurious behavior reported the lowest level of adversities and trauma symptoms, while adolescents with both NSSI and suicide attempts (5.7%) reported the highest levels compared to those with only NSSI or a suicide attempt. Adolescents reporting frequent NSSI reported more adversities and trauma symptoms than those with less frequent NSSI. Automatic functions, such as affect regulation, self-punishment and feeling-generation, were the most commonly reported functions of NSSI. Attempts in study I to confirm Nock and Prinstein’s (2004) four-factor model of underlying factors of NSSI functions resulted in a close to acceptable fit. An attempt to refine the factor analysis on this community sample of Swedish adolescents, using Mplus with cross-validation, was made in study III (n = 836). An exploratory factor analysis resulted in a three-factor model (social influence, automatic functions and non-conformist peer identification), which was validated in confirmatory analysis. In order to adhere more closely to learning theory and the concept of negative and positive reinforcement, the third factor was then split into two factors, resulting in a four-factor model (social influence, automatic functions, peer identification and avoiding demands), which showed excellent fit to the data in the confirmatory factor analysis. Study IV (n = 816) showed that NSSI frequency, gender (female), self-reported experience of emotional and physical abuse, having made a suicide attempt, prolonged illness or handicap and symptoms of depression and dissociation were significant predictors in the final model of the automatic functions, indicating that these variables are important in understanding the mechanisms underlying the need to engage in NSSI to regulate emotions, generate feelings, gain control or to self-punish. Symptoms of depression and dissociation mediated the relationship between sexual, physical and emotional abuse and the automatic  functions. Furthermore, frequency of NSSI, gender, emotional abuse, prolonged illness or handicap and symptoms of depression uniquely predicted automatic functions but not social functions. Self-reported experience of physical abuse, having made a suicide attempt, symptoms of anxiety and dissociation were significant in the final model of social functions, i.e., performing NSSI to influence or  communicate with others, to avoid demands or to identify with peers. Of these, symptoms of anxiety were uniquely associated with social functions. Symptoms of anxiety and dissociation mediated the relationship between physical abuse and social functions of NSSI. Taken together, this thesis has shown that NSSI is prevalent in Swedish adolescents and findings contribute to the discussion of a potential NSSI diagnosis. It is important to consider the effect of different types of negative life events and trauma symptoms in relation to NSSI in adolescents. Assessing the specific reinforcing functions of NSSI and the underlying factor structure can be helpful in developing functionally relevant individualized treatment. / Självskadebeteende, t ex att avsiktligt skära, bränna eller slå sig själv är potentiellt skadliga beteenden. Empiriska studier är viktiga för att kunna förebygga självskadebeteende hos ungdomar. Föreliggande avhandling syftar till att undersöka självskadebeteendets förekomst, funktion, karaktäristik och metoder hos svenska ungdomar, samt att undersöka relationen till negativa livshändelser och traumasymptom. Samtliga fyra empiriska studier hade en tvärsnittsdesign och baserades på 3,097 ungdomar i Östergötland, 15-17 år, i gymnasieskolans årskurs 1, vars skolklasser valts ut slumpmässigt och som besvarat självskattningsformulär. I studie I (n = 3,060) angav 17.2%, som svar på en allmän självskadefråga, att de avsiktligt skadat sig under sin livstid. När ungdomarna däremot svarade på en checklista med olika självskadebeteenden, angav 35.6% att de hade ägnat sig åt någon typ av självskadebeteende under det senaste året. De vanligaste metoderna var att avsiktligt bita eller slå sig själv, sudda på huden och att skära sig. De föreslagna diagnoskriterierna för icke-suicidal självskada i DSM-5 resulterade i en förekomst av 6.7%. Studie II (n = 2,964) visade att ungdomar utan självskadebeteende rapporterade de lägsta antalet negativa livshändelser och traumasymptom, medan de med erfarenhet av både självskadebeteende och självmordsförsök (5.7%) rapporterade de högsta antalen jämfört med de med endast självskadebeteende eller självmordsförsök. Ungdomar med fler självskadetillfällen rapporterade fler negativa livshändelser och traumasymptom än de med färre tillfällen. Automatiska/intrapersonella funktioner, såsom att generera och reglera känslor samt att straffa sig själv var de vanligaste funktionerna som rapporterades. Försök att konfirmera Nock och Prinsteins (2004) fyrfaktormodell av underliggande funktionsfaktorer i studie I resulterade i en modell med nära acceptabel passform. Ett försök att förbättra faktoranalysen på den aktuella urvalsgruppen gjordes med Mplus i studie III (n = 836). En exploratorisk analys resulterade i en trefaktormodell (interpersonell påverkan, automatisk/intrapersonell funktion samt ”icke-konformistisk” kamratidentifikation), vilken även validerades i den konfirmatoriska analysen. Med utgångspunkt i inlärningsteori och begreppen negativ och positiv förstärkning delades därefter den tredje faktorn upp i två faktorer. Det resulterade i en fyrfaktormodell (interpersonell påverkan, automatisk/intrapersonell funktion, kamratidentifikation samt undvikande av krav). Fyrfaktormodellen visade utmärkt passform i den konfirmatoriska analysen. Studie IV (n = 816) visade att självskadebeteendets frekvens, kön (flicka), självrapporterade erfarenheter av psykisk och fysisk misshandel, självmordsförsök, kronisk sjukdom eller handikapp under uppväxten, liksom symptom på depression och dissociation predicerade automatiska självskadefunktioner. De variablerna är potentiellt viktiga för förståelsen av de mekanismer som är involverade när ungdomar skadar sig själva för att generera och reglera känslor, få kontroll, liksom att straffa sig själva. Relationen mellan psykisk och fysisk misshandel och de automatiska funktionerna medierades av symptom på depression och dissociation. Självskadefrekvens, kön, psykisk misshandel, sjukdom/handikapp och symptom på depression predicerade enbart automatiska men inte sociala funktioner. Självrapporterad fysisk misshandel, självmordsförsök, symptom på ångest och dissociation var signifikanta prediktorer för de sociala funktionerna (att påverka/kommunicera med andra, undvika krav eller identifiera sig med kamrater). Ångestsymptom var unikt associerade med sociala funktioner. Symptom på ångest och dissociation medierade vidare relationen mellan fysisk misshandel och sociala självskadefunktioner. Sammanfattningsvis visade resultaten att självskadebeteende är vanligt förekommande hos ungdomar. Avhandlingen bidrar med empiri till diskussionen gällande icke suicidal självskada i DSM-5. Det är viktigt att beakta olika negativa livserfarenheter och traumasymptom i relation till självskadebeteende hos ungdomar. Att undersöka självskadebeteendets funktioner kan vara kliniskt hjälpsamt för att utveckla och utvärdera individuellt anpassade behandlingsstrategier.