Evidence-based assessment/Self harm (assessment portfolio)

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Subject classification: this is a psychology resource.

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

Medical disclaimer: This page is for educational and informational purposes only and may not be construed as medical advice. The information is not intended to replace medical advice offered by physicians. Please refer to the full text of the Wikiversity medical disclaimer.

What is a "portfolio"?

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

Preparation phase

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

Risk assessment

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

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

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

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

• Do you have confidence that you could attempt suicide?

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

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

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

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

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

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

Suicidal Ideation

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

Diagnostic criteria for NSSI

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).
• 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

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

• To see prevalence rates across multiple disorders, click here.

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

Prediction phase

Psychometric properties of screening instruments of NSSI

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

• Screenings are used as part of the prediction phase of assessment; for more information on interpretation of this data, or how screenings fit in to the assessment process, click here.

• For a list of more broadly reaching screening instruments, click here.

Screening measures for (Self Harm)
Measure	Format (Reporter)	Age Range	Administration/ Completion Time	Where to Access
Suicidal Behaviors Questionnaire (SBQ)	Self-report	13-18	5 minutes	Printable PDF of SBQ
Beck Scale for Suicide Ideation (BSI)	Self-report	17+	5-10 minutes	Link to purchase BSI
Suicide Ideation Questionnaire for Children (SIQ-JR)	Self-report	12-15	15 items	Link to purchase SIQ-JR

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

Likelihood ratios and AUCs of screening measures for NSSI

• 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	.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

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

Prescription phase

Gold standard diagnostic interviews

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

Recommended diagnostic instruments for NSSI

Diagnostic instruments for NSSI
Measure	Format (Reporter)	Age Range	Administration Time	Where to Access
Suicide Behaviors Questionnaire-Revised (SBQ-R)	Self-report	18+	5-10 mins	Link to free download:SBQ-R
Suicide Attempt Self-Injury Interview (SASII)	Structured interview	18+	Varies	Link to free download:SASII
Self Injurious Thoughts and Behaviors Interview (SITBI)	Structured interview	11+	3-15 mins	Link to free download:SITBI

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

Process phase

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

Outcome and severity measures

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

Treatment

• Please refer to the page on non-suicidal self injury for more information on available treatment for NSSI
• Go to Effective Child Therapy for a curated resource on effective treatments for NSSI.

Information on treatment for NSSI

According to Nock (2010), 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). Dialectical behavioral therapy (DBT) 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. Cognitive behavioral therapy (CBT) 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; Weinberg, Gunderson, Hennen, & Cutter, 2006). Although MACT may be a promising intervention (Muehlenkamp, 2006), 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), 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. Pharmacology 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). 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; Goodyer et al., 2007). 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). 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), although the long-term effects are unknown. Prevention programs Jacobs, Walsh, McDade, and Pigeon (2009) 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).

External resources

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

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