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Evidence-based assessment/Self harm (assessment portfolio)/extended version

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EBA Implementation
Assessment phases
Steps 1-2: Preparation phase

Preparation phase

Steps 3-5: Prediction phase

Prediction phase

Steps 6-9: Prescription phase

Prescription phase

Steps 10-12: Process/progress/outcome phase

Process phase

What is a "portfolio"?

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  • For background information on what assessment portfolios are, click the link in the heading above.
  • Does all this feel like TMI? Click here to go to a condensed version.

Preparation phase

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

Suicidal Ideation

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Self-Injurious Thoughts and Behaviors Interview[1]. Suicide has an article on Wikipedia.

Suicidal Behavior

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Diagnostic criteria for NSSI

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DSM-5 Criteria for NSSI

  • Nonsuicidal self-injury is currently a proposed disorder in need of further research in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5)[2].
  • The criteria for NSSI can be found under Conditions for Further Study in DSM-5.

ICD-11 Criteria for NSSI

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

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

Base rates of NSSI in different populations and clinical settings

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

  • To see prevalence rates across multiple disorders, click here.
Demography Setting Base Rate Diagnostic Method Reference Best Recommended For
International Young adult non-clinical sample 13.4% Meta-analysis, controlling for methodological differences across studies Lifetime frequency; Swannell et al., 2014[3]
All of U.S.A. Adult community sample 23% Self-report measure (questions based on proposed DSM-V criteria for NSSI Disorder; FASM) Lifetime frequency; Andover, 2015[4]
North East Adolescent inpatient sample 50% Self-report measure (ISAS), based on DSM-V criteria for NSSI Disorder Lifetime frequency; Glenn & Klonsky, 2013[5]
Sweden Adolescent community sample 43.4% Combined self-report measure (FASM) and interview (SITBI) Lifetime frequency; Zetterqvist et al., 2013[6]
U.S.A. Adult outpatient sample 11.4% Chart review, not based on DSM-V criteria Lifetime frequency; Selby et al., 2012[7]
All of U.S.A. Adolescent epidemiological 13.0%-23.2% Variable assessment methods Lifetime frequency; Jacobson & Gould, 2007[8]
North East Adolescent non-clinical sample 7.5% Self-report measure within the last year; Hilt et al., 2008[9]
North East Adolescent inpatient sample 60% Self-report measure (FASM) lifetime frequency; Nock et al., 2006[10]
United Kingdom Incarcerated sample 52% Self-report measure (FASM) Gray et al., 2003
International Adults from sexual minorities (LGBT) samples 36.53% Various self-report questionnaires Liu et al., 2019

Search terms: [Non-suicidal self-injury or NSSI or Self harm] AND [children OR adolescents] AND [prevalence OR incidence OR epidemiological] in PsychInfo and Google Schola

Prediction phase

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Comparison of screening measures

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Descriptions of types of NSSI screenings

Differences between types of NSSI measures

  1. Omnibus Measures
    • Assess several NSSI domains
    • These tests are the most comprehensive compared to other measures
  2. Functional Measures
    • Helpful for understanding why people self-injure
    • These tests assess motives for, or functions of, NSSI
  3. Behavioral Measures
    • Primarily assess one's history of NSSI behaviors
    • These measures are useful for assessment methods used and NSSI frequency
  4. Brief Measures
    • Include a single item or a few items to assess NSSI
    • These may be best when conducting a brief assessment

Recommendations

  • Omnibus measures are highly recommended over all other types of measures.
    • The SITBI is the best clinical interview for assessing adolescent NSSI
    • The SASII was designed to assess NSSI among adults.

Scope of screening instruments for NSSI

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Click here for cross-screening component analysis
Category of Screening Instrument No. Items History Methods Frequency Lethality Intent of Functions History of Suicidality
Omnibus Suicidal Behaviors Questionnaire (SBQ) 90
Omnibus Self-Harm Behavior Questionnaire (SHBQ) 32
Functional Functional Assessment of Self-Mutilation (FASM) 22
Functional Inventory of Statements About Self-Harm (ISAS) 39
Functional Self-Injury Questionnaire (SIQ) 30
Functional Self-Injury Motivation Scale (SIMS) 35
Functional Self-Harm Reasons Questionnaire (SHRQ) - Revised 21
Behavioral Deliberate Self-Harm Inventory (DSHI) 17
Behavioral Self-Harm Inventory (SHI) 22
Brief Schedule for Nonadaptive and Adaptive Personality (SNAP) Items 2
Brief Trauma Symptom Inventory (TSI) Item 1
  • Note: SNAP has 375 items in the total measure; TSI has 100 items in the total measure.
  • Search terms: [Non-suicidal self-injury or NSSI or Self harm] AND [children OR adolescents] AND [assessment] in PsychINFO and Google ScholarTreatment
  • Sources consulted: Klonsky, E. D., & Lewis, S. P. (2014). Assessment of nonsuicidal self-injury. In M. K. Nock, M. K. Nock (Eds.), The Oxford handbook of suicide and self-injury (pp. 337-351). New York, NY, US: Oxford University Press.; Nock (Eds.), Understanding non-suicidal self-injury: Origins, assessment, and treatment. Washington, DC: Am. Psychol. Assoc.

Psychometric properties of screening instruments of NSSI

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

  • Screenings are used as part of the prediction phase of assessment; for more information on interpretation of this data, or how screenings fit in to the assessment process, click here.
  • For a list of more broadly reaching screening instruments, click here.
Instrument (Reference) Type of screeening Format (Reporter) Age Range Administration Time Internal Consistency Interrater Reliability Test-Retest Reliability Construct Validity Highly Recommended Free and Accessible Measures
Suicidal Behaviors Questionnaire (SBQ) [11] Omnibus G NA A G Yes
Self-Harm Behavior Questionnaire (SHBQ) [12] Omnibus G NA A G Not free
Functional Assessment of Self-Mutilation (FASM)[13] Functional A NA U A
Inventory of Statements About Self-Harm (ISAS) [14] Functional G NA G G
Self-Injury Questionnaire (SIQ) [15] *Not Free* Functional G NA U A Not free
Self-Injury Motivation Scale (SIMS)[16] Functional G NA U A
Self-Harm Reasons Questionnaire (SHRQ) [17] Functional G NA U A
Deliberate Self-Harm Inventory (DSHI) [18] Behavioral G NA G G
Self-Harm Inventory (SHI) Behavioral A NA U A
SNAP Items[19] Brief NA NA U A
Trauma Symptom Inventory (TSI) [20] Brief NA NA U A
Scale for Suicide Ideation (SSI) Other G U U G Yes
Suicide Behaviors Interview (SBI) Other E E U A
Child Suicide Potential Scales (CSPS) Other A E U G Yes
Beck Scale for Suicide Ideation (BSI) Other E NA U G Yes
Suicide Behaviors Questionnaire for Children (SBQ-C) Other G NA A A
Suicide Ideation Questionnaire for Children (SIQ-JR) Other G NA A G Yes
Suicide Probability Scale (SPS) Other E NA U A
Columbia Suicide Screen (CSS) Other G NA L A
Harkavy Asnis Suicide Scale (HASS) Other E NA U G

Note: L = Less than adequate; A = Adequate; G = Good; E = Excellent; U = Unavailable; NA = Not applicable

  • Sources consulted: Klonsky, E. D., & Lewis, S. P. (2014). Assessment of nonsuicidal self-injury. In M. K. Nock, M. K. Nock (Eds.) , The Oxford handbook of suicide and self-injury (pp. 337-351). New York, NY, US: Oxford University Press.[21]; Nock (Eds.), Understanding non-suicidal self-injury: Origins, assessment, and treatment. Washington, DC: Am. Psychol. Assoc.

Likelihood ratios and AUCs of screening measures for NSSI

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  • For a list of the likelihood ratios for more broadly reaching screening instruments, click here.
Screening Measure (Primary Reference) AUC LR+ (score) LR- (score) Clinical Generalizability Download
Child Behavior Checklist (CBCL) Anxious/Depressed Scale T-score[22] .70 (N=470) 3.78 (60+) .39 (<60) High. Large diverse sample with mixed depression sample compared to samples without depression. Not free

Interpreting NSSI screening measure scores

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

Prescription phase

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Gold standard diagnostic interviews

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  • For a list of broad reaching diagnostic interviews sortable by disorder with PDFs (if applicable), click here.

Coverage of interviews for NSSI

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Scope of diagnostic interviews for NSSI
Instrument No. Items History Methods Frequency Lethality Intent of Functions History of Suicidality
Omnibus Measures
Suicide Attempt Self-Injury Interview (SASII) 31 X X X X X X
Self-Injurious Thoughts and Behaviors Interview (SITBI) 169 X X X X X X
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Diagnostic instruments for NSSI
Instrument (Reference) Type of screeening Format (Reporter) Age Range Administration Time Internal Consistency Interrater Reliability Test-Retest Reliability Construct Validity Content Validity Highly Recommended Free and Accessible Measures
Beck Scale for Suicidal Ideation (BSI) Self-report questionnaire 17+ 5-10 mins E A G No
  • Link to purchase [1]
Suicidal Behaviors Questionnaire-Revised (SBQ-R) Self-report 18+ 5-10 mins .87 E E Yes SBQ-R
Self-Harm Behavior Questionnaire (SHBQ) Self-report questionnaire adolescents Not Reported E G G
Suicide Attempt Self-Injury Interview (SASII) [23] Omnibus G E E G SASII
Self Injurious Thoughts and Behaviors Interview (SITBI) [24] Omnibus NA E A G SITBI
Suicidal Ideation Questionnaire (SIQ) Self-report questionnaire 12-18 years old 10 minutes NA SIQ
Suicidal Ideation Questionnaire (SIQ-JR) Self-report Questionnaire Middle School aged children 10 minutes NA test-retest: r -0.93 (males) r = .87 (females) SIQ-JR

Note: L = Less than adequate; A = Adequate; G = Good; E = Excellent; U = Unavailable; NA = Not applicable

Process phase

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

Process measures

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Outcome and severity measures

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  • This table includes clinically significant benchmarks for NSSI specific outcome measures
  • Information on how to interpret this table can be found here.
  • Additionally, these vignettes might be helpful resources for understanding appropriate adaptation of outcome measures in practice.
  • For clinically significant change benchmarks for the CBCL, YSR, and TRF total, externalizing, internalizing, and attention benchmarks, see here.
Clinically significant change benchmarks with common instruments for NSSI
Measure Subscale Cut-off scores Critical Change
(unstandardized scores)
Benchmarks Based on Published Norms
A B C 95% 90% SEdifference

Treatment

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Click here for information on treatment for NSSI

According to Nock (2010)[25], no treatment for NSSI could be considered "evidence-based." However, recent years have seen an increase in intervention trials for NSSI. Although limited due to lack of consistency in defining and measuring NSSI, this work could provide insight into potential best practices for treating this condition (Andover, 2015)[4].

  1. Dialectical behavioral therapy (DBT)
    1. Dialectical Behavior Therapy has been shown to be effective in treating individuals with Borderline Personality Disorder (BPD) who engage in NSSI; however it has not been shown to be better than treatment as usual in a sample of individuals without BPD. In the absence of a better option, a DBT approach to treatment is the most evidence based.
  2. Cognitive behavioral therapy (CBT)
    1. Few research studies have tested cognitive-behavioral therapy (CBT) as a treatment specifically for NSSI. However, some studies have evaluated the efficacy of CBT trials in treating self-injury with and without suicidal intent. Manual-assisted cognitive therapy (MACT) is a 6-session CBT intervention focusing on functions of deliberate self-harm, emotion regulation, problem-solving skills, and relapse prevention. MACT has demonstrated mixed results for decreasing NSSI frequency and severity among adults (Tyrer et al., 2003[26]; Weinberg, Gunderson, Hennen, & Cutter, 2006)[27]. Although MACT may be a promising intervention (Muehlenkamp, 2006)[28], it should be evaluated in future studies. In one adolescent treatment trial, the Adolescent Depression Antidepressant Psychotherapy Trial (ADAPT), a decrease in NSSI behaviors was found at post-treatment for both SSRI and SSRI+CBT groups (Goodyer et al., 2007)[29], although no differences were found between groups. In sum, findings from efficacy trials of CBT on NSSI outcomes are mixed, and more trials examining CBT as a treatment specifically for NSSI are needed.
  3. Pharmacology
    1. Pharmacological interventions are especially scarce. However, one study found that fluoxetine was effective at reducing NSSI frequency in a sample of 22 adults with major depressive disorder and either BPD or schizotypal personality disorder (Markovitz et al, 1991)[30]. A second trial found that antidepressant medications alone (SSRIs and SNRIs) were as effective as medication plus CBT in reducing NSSI among adolescents with MDD (Brent et al., 2009[31]; Goodyer et al., 2007)[29]. Ziprasidone, an atypical antipsychotic, was found to be more effective in reducing NSSI behaviors among adolescents compared to another neuroleptic medication (Libal et al., 2005)[32]. Clonidine has also been effective as an intervention for acute NSSI urges and feelings of tension among a sample of patients with BPD (Philipsen et al., 2004)[33], although the long-term effects are unknown.
  4. Prevention programs
    1. Jacobs, Walsh, McDade, and Pigeon (2009)[34] developed the only known prevention program for NSSI, the Signs of Self-Injury program (SOSI). This school-based prevention program is designed to increase awareness about NSSI among adolescents through psychoeducation about warning signs and symptoms and improvement of help-seeking behaviors and attitudes. One test of effectiveness and acceptance found the program to be feasible and effective at changing attitudes toward NSSI and increasing help-seeking among students (Muehlenkamp et al., 2010)[35].

External resources

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

References

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Liu, R. T., Sheehan, A. E., Walsh, R. F., Sanzari, C. M., Cheek, S. M., & Hernandez, E. M. (2019). Prevalence and correlates of non-suicidal self-injury among lesbian, gay, bisexual, and transgender individuals: A systematic review and meta-analysis. Clinical psychology review, 74, 101783
  1. ↑ Nock, Matthew K.; Holmberg, Elizabeth B.; Photos, Valerie I.; Michel, Bethany D. (2007). "Self-Injurious Thoughts and Behaviors Interview: Development, reliability, and validity in an adolescent sample.". Psychological Assessment 19 (3): 309–317. doi:10.1037/1040-3590.19.3.309. ISSN 1939-134X. http://doi.apa.org/getdoi.cfm?doi=10.1037/1040-3590.19.3.309. 
  2. ↑ American Psychiatry Association (2013). Diagnostic and statistical manual of mental disorders : DSM-5 (5th ed.). Washington [etc.]: American Psychiatric Publishing. ISBN 9780890425558. 
  3. ↑ Swannell, SV; Martin, GE; Page, A; Hasking, P; St John, NJ (June 2014). "Prevalence of nonsuicidal self-injury in nonclinical samples: systematic review, meta-analysis and meta-regression.". Suicide & life-threatening behavior 44 (3): 273-303. PMID 24422986. 
  4. ↑ 4.0 4.1 Andover, MS (30 October 2014). "Non-suicidal self-injury disorder in a community sample of adults.". Psychiatry research 219 (2): 305-10. PMID 24958066. 
  5. ↑ Glenn, CR; Klonsky, ED (August 2013). "Reliability and validity of borderline personality disorder in hospitalized adolescents.". Journal of the Canadian Academy of Child and Adolescent Psychiatry = Journal de l'Academie canadienne de psychiatrie de l'enfant et de l'adolescent 22 (3): 206-11. PMID 23970909. 
  6. ↑ Zetterqvist, M; Lundh, LG; Svedin, CG (August 2013). "A comparison of adolescents engaging in self-injurious behaviors with and without suicidal intent: self-reported experiences of adverse life events and trauma symptoms.". Journal of youth and adolescence 42 (8): 1257-72. PMID 23212349. 
  7. ↑ Selby, EA; Bender, TW; Gordon, KH; Nock, MK; Joiner TE, Jr (April 2012). "Non-suicidal self-injury (NSSI) disorder: a preliminary study.". Personality disorders 3 (2): 167-75. PMID 22452757. 
  8. ↑ Jacobson, CM; Gould, M (2007). "The epidemiology and phenomenology of non-suicidal self-injurious behavior among adolescents: a critical review of the literature.". Archives of suicide research : official journal of the International Academy for Suicide Research 11 (2): 129-47. PMID 17453692. 
  9. ↑ Hilt, L. M.; Nock, M. K.; Lloyd-Richardson, E. E.; Prinstein, M. J. (7 May 2008). "Longitudinal Study of Nonsuicidal Self-Injury Among Young Adolescents: Rates, Correlates, and Preliminary Test of an Interpersonal Model". The Journal of Early Adolescence 28 (3): 455–469. doi:10.1177/0272431608316604. 
  10. ↑ Nock, MK; Joiner TE, Jr; Gordon, KH; Lloyd-Richardson, E; Prinstein, MJ (30 September 2006). "Non-suicidal self-injury among adolescents: diagnostic correlates and relation to suicide attempts.". Psychiatry research 144 (1): 65-72. PMID 16887199. 
  11. ↑ Linehan, M. M. (1981). Suicides behaviors questionnaire. Seattle: University of Washington. 
  12. ↑ Gutierrez, PM; Osman, A; Barrios, FX; Kopper, BA (December 2001). "Development and initial validation of the Self-harm Behavior Questionnaire.". Journal of personality assessment 77 (3): 475-90. PMID 11781034. 
  13. ↑ Lloyd-Richardson, E. E.; Kelley, M. L.; Hope, T. (April 1997). "Self-mutilation in a community sample of adolescents: Descriptive characteristics and provisional prevalence rates". Poster session presented at the Annual Meeting of the Society for Behavioral Medicine (New Orleans, LA). 
  14. ↑ http://www2.psych.ubc.ca/~klonsky/publications/ISASmeasure.pdf
  15. ↑ Santa Mina, EE; Gallop, R; Links, P; Heslegrave, R; Pringle, D; Wekerle, C; Grewal, P (April 2006). "The Self-Injury Questionnaire: evaluation of the psychometric properties in a clinical population.". Journal of psychiatric and mental health nursing 13 (2): 221-7. PMID 16608478. 
  16. ↑ Osuch, EA; Noll, JG; Putnam, FW (1999). "The motivations for self-injury in psychiatric inpatients.". Psychiatry 62 (4): 334-46. PMID 10693230. 
  17. ↑ Lewis, SP; Santor, DA (February 2008). "Development and validation of the self-harm reasons questionnaire.". Suicide & life-threatening behavior 38 (1): 104-15. PMID 18355112. 
  18. ↑ Gratz, K. L. (4 December 2001). "Measurement of deliberate self-harm: Preliminary data on the deliberate self-harm inventory". Journal of Psychopathology and Behavioral Assessment 23 (4): 253-263. doi:0882-2689/01/1200-0253/0. 
  19. ↑ Clark, L. A. (1996). Schedule for adaptive and nonadaptive personality: Manual for administration, scoring, and interpretation. Minneapolis: University of Minnesota Press. 
  20. ↑ Briere, J (1995). Trauma symptom inventory (TSI) professional manual.. Odessa, FL: Psychological Assessment Resources. 
  21. ↑ Klonsky, E. D.; Lewis, S. P. (2013). "Assessment of nonsuicidal self-injury". In Nock, M. K.. The Oxford handbook of suicide and self-injury. New York: Oxford University Press. pp. 337-351. ISBN 9780195388565. 
  22. ↑ Achenbach, Thomas M. (1991). Child behavior checklist for ages 4-18 ([11th print.] ed.). Burlington, VT: T.M. Achenbach. ISBN 0938565087. 
  23. ↑ Linehan, MM; Comtois, KA; Brown, MZ; Heard, HL; Wagner, A (September 2006). "Suicide Attempt Self-Injury Interview (SASII): development, reliability, and validity of a scale to assess suicide attempts and intentional self-injury.". Psychological assessment 18 (3): 303-12. PMID 16953733. 
  24. ↑ Nock, MK; Holmberg, EB; Photos, VI; Michel, BD (September 2007). "Self-Injurious Thoughts and Behaviors Interview: development, reliability, and validity in an adolescent sample.". Psychological assessment 19 (3): 309-17. PMID 17845122. 
  25. ↑ Nock, MK (2010). "Self-injury.". Annual review of clinical psychology 6: 339-63. PMID 20192787. 
  26. ↑ Tyrer, P; Thompson, S; Schmidt, U; Jones, V; Knapp, M; Davidson, K; Catalan, J; Airlie, J et al. (August 2003). "Randomized controlled trial of brief cognitive behaviour therapy versus treatment as usual in recurrent deliberate self-harm: the POPMACT study.". Psychological medicine 33 (6): 969-76. PMID 12946081. 
  27. ↑ Weinberg, I; Gunderson, JG; Hennen, J; Cutter CJ, Jr (October 2006). "Manual assisted cognitive treatment for deliberate self-harm in borderline personality disorder patients.". Journal of personality disorders 20 (5): 482-92. PMID 17032160. 
  28. ↑ Muehlenkamp, J. J. (2006). "Empirically supported treatments and general therapy guidelines for non-suicidal self-injury". Journal of Mental Health Counseling 28: 166-185. 
  29. ↑ 29.0 29.1 Goodyer, I; Dubicka, B; Wilkinson, P; Kelvin, R; Roberts, C; Byford, S; Breen, S; Ford, C et al. (21 July 2007). "Selective serotonin reuptake inhibitors (SSRIs) and routine specialist care with and without cognitive behaviour therapy in adolescents with major depression: randomised controlled trial.". BMJ (Clinical research ed.) 335 (7611): 142. PMID 17556431. 
  30. ↑ Markovitz, PJ; Calabrese, JR; Schulz, SC; Meltzer, HY (August 1991). "Fluoxetine in the treatment of borderline and schizotypal personality disorders.". The American journal of psychiatry 148 (8): 1064-7. PMID 1853957. 
  31. ↑ Brent, DA (2009). "The treatment of SSRI-resistant depression in adolescents (TORDIA): in search of the best next step.". Depression and anxiety 26 (10): 871-4. PMID 19798756. 
  32. ↑ Libal, Gerhard; Plener, Paul L.; Ludolph, Andrea G.; Fegert, Joerg M. (June 2005). "Ziprasidone as a Weight-Neutral Alternative in the Treatment of Self-Injurious Behavior in Adolescent Females". Child and Adolescent Psychopharmacology News 10 (4): 1–6. doi:10.1521/capn.2005.10.4.1. 
  33. ↑ Philipsen, A; Richter, H; Schmahl, C; Peters, J; Rüsch, N; Bohus, M; Lieb, K (October 2004). "Clonidine in acute aversive inner tension and self-injurious behavior in female patients with borderline personality disorder.". The Journal of clinical psychiatry 65 (10): 1414-9. PMID 15491247. 
  34. ↑ Jacobs, D; Walsh, B. W.; McCade, M; Pigeon, S (2009). Signs of self-injury prevention manual. Wellesley Hills, MA: Screening for Mental Health. 
  35. ↑ Muehlenkamp, JJ; Walsh, BW; McDade, M (March 2010). "Preventing non-suicidal self-injury in adolescents: the signs of self-injury program.". Journal of youth and adolescence 39 (3): 306-14. PMID 19756992. 
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