Lamb 2005 A Systematic Review of Deliberate Self - Harm Assessment Instruments

Pepperdine University
Graduate School of Education and Psychology
A SYSTEMATIC REVIEW OF DELIBERATE SELF-HARM ASSESSMENT
INSTRUMENTS
A clinical dissertation submitted in partial satisfaction
of the requirements for the degree of Doctor of Psychology
by
Toby F. Lamb
July, 2005
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
UMI Number: 3191655
Copyright 2005 by
Lamb, Toby F.
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P.O. Box 1346
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This clinical dissertation, written by
Toby F. Lamb
under the guidance of a Faculty Committee and approved by its members, has been
submitted to and accepted by the Graduate Faculty in partial fulfillment of the
requirements for the degree of
DOCTOR OF PSYCHOLOGY
April 6, 2005
Faculty Committee:
Edward P. Shafi .D., ABPP, Chairperson
Jd$ K. Asaihen, Ph.D.
Teri M. Pokraj&efT’sy.D.
Robert A. deMayo, Ph.D.

Associate Dean
Mg£rgaf£t J. Web&, Ph.D.

Dean
©Copyright by Toby F. Lamb (2005)
All Rights Reserved
TABLE OF CONTENTS
Page
LIST OF TABLES...................................................................................................................vi
ACKNOWLEDGMENTS..................................................................................................... vii
VITAE.....................................................................................................................................viii
ABSTRACT............................................................................................................................. xi
CHAPTER 1: PROBLEM STATEMENT...............................................................................1
Introduction................................................................................................................... 1
Purpose and Importance of the Review......................................................................3
Summary....................................................................................................................... 4
CHAPTER II: REVIEW OF LITERATURE......................................................................... 6
Conceptual Issues..........................................................................................................6
Terminology..................................................................................................... 6
Attempts at Classification............................................................................... 8
Conceptual Definition....................................................................................12
Prevalence of Self-Harm............................................................................................ 12
Characteristics of Self-Harming Populations............................................................13
Phenomenology of Self-Harm...................................................................................14
Functions of Self-Harm.............................................................................................. 15
Foundations of Deliberate Self-Harm....................................................................... 17

Childhood Physical Abuse............................................................................ 17
Childhood Sexual Abuse................................................................................18
Neglect............................................................................................................ 19
Diagnostic Challenges of Self-harm.........................................................................20

Differentiation from Suicide.........................................................................20
Clinical Correlates.........................................................................................23
Dissociation....................................................................................... 24
Eating Disorders................................................................................ 25
Borderline Personality Disorder......................................................27
Deliberate Self-Harm as a Distinct Syndrome............................................ 28
Measurement of Deliberate Self-Harm.................................................................... 31
Summary.....................................................................................................................33
CHAPTER III: PLAN OF ACTION..................................................................................... 35
Psychological Assessment........................................................................................ 35
Psychometric Evaluation.......................................................................................... 37
Reliability....................................................................................................... 38
Internal Consistency..........................................................................39
Test-Retest Reliability..................................................................... 39
Interrater Reliability..........................................................................39
Validity..........................................................................................................40
Content Validity................................................................................41
Criterion-Related V alidity............................................................... 42
Factorial Validity..............................................................................44
Construct Validity.............................................................................46
Strategies for Identifying Self-Harm Measures.......................................................47

Criteria for Inclusion..................................................................................... 47
Criteria for Exclusion.................................................................................... 48
Categorization of Review .............................................................................49
Plan for Evaluating Self-Harm Measures................................................................ 49

Operational Definition.................................................................................. 49
Development/Samples Studied.................................................................... 51
Dimensionality...............................................................................................51
Reliability.......................................................................................................52
Validity.......................................................................................................... 52
Summary.................................................................................................................... 52
CHAPTER IV: INSTRUMENT REVIEW...........................................................................53
Detection Instruments................................................................................................53
Self-Report Detection Instruments.............................................................. 54
Deliberate Self-Harm Inventory (DSHI)........................................ 54
Self-Harm Behavior Questionnaire (SHBQ).................................. 56
Self-Harm Inventory (SHI).............................................................. 59
Self-Injury Survey (SIS).................................................................. 63
Functional Assessment of Self-Mutilation (FASM)...................... 65
Self-Injury Questionnaire (SIQ )......................................................69
Self-Harm Behavior Survey (SHBS)...............................................71
iv
Self-Injurious Behaviors Questionnaire (SIBQ).............................73
Self-Injury Motivation Scale - Version 2 (SIMS-2).......................76
Clinician-Administered Detection Instruments.......................................... 79
Self-Injury Interview (SII)............................................................... 79
Parasuicide History Inventory (PH I)...............................................81
Lifetime Parasuicide Count (LPC)...................................................85
Instruments for Assessing Severity of Self-Harm Behavior................................... 88

Self-Inflicted Injury Severity Form (SIISF)................................... 89
Self-Injury Trauma Scale (SIT)....................................................... 91
Summary.....................................................................................................................93
CHAPTER V: DISCUSSION..............................................................................................104
Overview o f the Study.............................................................................................104
Assumptions and Limitations................................................................................. 104
Discussion of the Findings...................................................................................... 105
Implications of the Findings................................................................................... 106
Impediments to the Field and Suggestions for Future Development....................108
Conclusion................................................................................................................I l l
REFERENCES.....................................................................................................................113
LIST OF TABLES
Page
Table 1: Instrument Descriptions................................................................................ 95
Table 2: Instrument Reliability Estimates...................................................................99
Table 3: Instrument Validity Estimates..................................................................... 101
vi
ACKNOWLEDGMENTS
The culmination of this document and my doctoral degree could not have been
accomplished without the many people who have played a part in my life. It would be
impossible to acknowledge them all; however, the following persons have made the most
recent, lasting, and significant contributions. I would first like to extend my appreciation
to my parents, Don and Regina Lamb, who have always encouraged my curiosity and
intellectual pursuits; to my grandparents, Russell and Mary Lamb, who generously
supported me through many years of unpaid graduate training; and to the love of my life,
Patricia, who has been gracious enough to suffer alongside me throughout this journey.
Lastly, I would also like to extend my appreciation to Dr. Edward Shafranske, Dr. Joy
Asamen, and Dr. Teri Pokrajac for their guidance, support, and feedback throughout the
dissertation process. I have lamented much, grown immeasurably, and learned the value
of persistence.
vii
VITAE
Toby F. Lamb, Psy.D.
Education:
1999-2005 Pepperdine University, Culver City, CA

Psy.D. Clinical Psychology
1997-1999 New Mexico Highlands University, Las Vegas, NM

M.S., General Psychology
1990-1995 San Diego State University, San Diego, CA

B.A., Psychology
Clinical Training:
2002-2003 Sparks M. Matsunaga Veteran’s Affairs Medical Center, Honolulu, HI

Pre-Doctoral Internship
2001-2001 Harbor-UCLA Medical Center, Torrance, CA

Doctoral Externship
2001-2002 Pepperdine University Community Counseling Center, Culver City, CA

Doctoral Externship
2000-2001 Del Amo Hospital, National Treatment Center, Torrance, CA

Doctoral Externship
1999-2000 Pepperdine University Student Counseling Center, Malibu, CA

Doctoral Externship
Research Experience:
2003-2005 Doctoral Dissertation

Title: A Systematic Review o f Deliberate Self-Harm Assessment
Instruments
Chairperson: Edward Shafranske, Ph.D., ABPP
2004-present Co-Principal Investigator

Heads UP! Women: Responsible Drinking Project
Loyola Marymount University
2004-present Assistant Director

Heads UP! Men: Responsible Drinking Project
Loyola Marymount University
viii
2000-2001 Research Assistant
Del Amo Hospital, National Treatment Center
1998-1999 Masters Thesis

Title: The Effects o f Perceived Efficacy on Psychological Sense o f
Community
Chairperson: Jean Hill, Ph.D.
Research Support and Awards:
2004 Co-Principal Investigator

National Institutes of Health/NIAAA
Rapid Response to College Student Drinking Problem Grant Competition
1999 Student Research Award, APA Division 27

Seventh Biennial Conference on Community Research and Action
Poster: The Effects of Perceived Efficacy on Psychological Sense of
Community.
Professional Affiliations:
2005-present Los Angeles California Psychological Association
1996-present American Psychological Association
1998-present Psi Chi, The National Honor Society in Psychology
1998-2000 APA Division 27, Society for Research and Action
Positions Held:
1998-1999 Graduate Student Representative to the Facuity

New Mexico Highlands University
1997-1999 Campus Representative, APAGS

New Mexico Highland University
1998-1999 Treasurer, Psi Chi

New Mexico Highlands University
Manuscripts in Review:
LaBrie, J. W., Lamb, T., Quinlan, T., & Pedersen, E. R. (2005). The effect of a multi-
component motivational enhancement intervention for mandated or adjudicated
college students. Alcoholism: Experimental and Clinical Research.
ix
LaBrie, J., Lamb, T., & Schiffman, J. (2004). Changes in drinking patterns during the
transition to college among freshmen males. Journal of American College Health.
LaBrie, J., Pedersen, E., & Lamb, T. (2004). Heads UP! A Nested Intervention with
Freshmen Male College Students to Promote Responsible Drinking. Journal of
American College Health.
LaBrie, J. W., Pedersen, E., Lamb, T., Earleywine, M., Quinlan, T. (20054). A campus-
based group motivational intervention to reduce problematic drinking in freshmen
males. Journal of Substance Abuse Treatment.
Conference Presentations:
LaBrie, J., Lamb, T., & Pedersen, E. (2005, August). Evaluating a group motivational
interviewing intervention for adjudicated college students. Poster to be presented
at the annual convention of the American Psychological Association, Washington,
DC.
LaBrie, J., Pedersen, E., & Lamb, T. (2005, August). A group motivational intervention
to reduce problematic drinking with freshman males. Poster to be presented at the
annual convention of the American Psychological Association, Washington, DC.
LaBrie, J., Pedersen, E. & Lamb, T. (2005, June). A group motivational intervention to
reduce problematic drinking with college students. Poster presented at the annual
convention of the Research Society on Alcoholism, Santa Barbara, CA.
Lamb, T. & LaBrie, J. (2005, June). Changes in drinking patterns during the transition to
college among freshman males. Paper presentation delivered at the annual
convention of the Research Society on Alcoholism, Santa Barbara, CA.
Lamb, T. & LaBrie, J. (2005, April). Changes in drinking patterns during the transition to
college among freshman males. Poster presented at the annual convention of the
Western Psychological Association, Portland, OR.
Lamb, T. & Hill, J. (1999, June). The Effects of Perceived Efficacy on Psychological
Sense of Community. Poster presented at the biennial conference of the Society
for Community Research and Action: Division of Community Psychology (APA
Division 27), New Haven, CT.
ABSTRACT
A systematic review and critique of 14 of the most commonly used deliberate
self-harm (DSH) instruments were conducted. This review considered the conceptual and
psychometric properties of each instrument and was intended to provide clinicians and
researchers with a compendium of information and critique regarding the strengths,
weaknesses, and psychometric properties of commonly used instruments. While, several
instruments showed promise in accurately measuring specific aspects of DSH, others
lacked proper development, evaluation, or standardization for use. The instruments
reviewed exemplify the variability in psychometric properties across measures. Given the
difficulty with which current instruments validly and reliably measure fundamental
dimensions o f deliberate self-harm, the unhindered propagation of additional measures is
cautioned. Methodologically sound instrument development and evaluation is needed
from the field of deliberate self-harm as the valid and reliable measurement of deliberate
self-harm has become a limiting factor in the development of an accurate, clinically
useful, and effective body of knowledge.
xi
CHAPTER I
PROBLEM STATEMENT
Introduction
The act of deliberate self-harm has long been considered a challenging symptom
to understand and to manage within clinical practice. Deliberate self-harm has been
described as “a frightening barrier that keeps us from seeing a person who is lost, in pain,
and in desperate need of help” (Levenkron, 1998, p. 19). Unfortunately, due to limitations
in the ability to both accurately and reliably assess this clinical phenomenon little has
been done to peer behind this barrier. The related difficulties of defining deliberate self-
harm and creating valid and reliable assessment instruments have greatly impeded
research within the field. As such, studies of deliberate self-harm have not extended far
beyond descriptive and correlational examination. While the assessment of deliberate
self-harm can be approached in many ways, the intent of this dissertation is to contribute
to the development of our understanding of self-harm by critically examining our
methodological procedures for measuring self-harm. Thus, when the terms assess,
assessing, and assessment are used with in this document they denote the use of
structured clinical instruments (i.e., surveys, interview, and self-report tests) designed to
quantify data pertinent to deliberate self-harm.
While the act of deliberately harming oneself is extreme in nature, it is becoming
a more common occurrence and clinicians will more frequently encounter patients who
engage in these behaviors. In fact, it has been estimated that for every 100,000 people in
the population, anywhere from 720 to 5,930 of them engage in some form of deliberate
self-harm (Favazza, 1998).
The majority o f individuals who engage in deliberate self-harm follow similar
preparatory rituals and experience similar outcomes following the act. In response to
perceived loss, individuals who self-harm experience increasing levels of psychological
distress and psychophysiological arousal (Darche, 1990; Feldman, 1988; Gardner &
Gardner, 1975). The escalation of negative affect and physiological tension typically
elicit dissociative phenomenon (Rosenthal, Rinzler, Wallsh, & Klausner, 1972; Simpson,
1976; Winchel & Stanley, 1991) leading to the act of painless self-harm (Ross & McKay,
1979; Simpson, 1976; Walsh & Rosen, 1988). Following the event negative affects,
tension, and dissociative processes abate (Conn & Lion, 1983; Feldman).
It is known that certain abusive behaviors (i.e., neglect, emotional abuse, sexual
abuse, and physical abuse), as well as separation and loss in early childhood, are rather
common in the backgrounds of those who self-harm (van der Kolk, Perry, & Herman,
1991). In addition, the earlier the trauma occurs in the development o f the child, the more
severe the subsequent self inflicted damage (van der Kolk et al.). As such, self-harm is
often strongly associated with borderline personality disorder and dissociative disorders
(Herpetz, 1995; Stone, 1987; van der Kolk et al.; Zlotnick, Mattia, & Zimmerman, 1999).
Moreover, it has been found that the potential for serious harm, and even death, rises
dramatically when self-harm is used as a coping mechanism (Dulit, Ryer, Leon, Brodsky,
& Frances, 1994).
While the phenomenology, suspected etiological, and clinical correlates are rather
well established within the literature, the research base is replete with methodological
flaws that hinder the consolidation of the empirical findings into a coherent
understanding of the phenomena. The severity of this disorder emphasizes the importance
of developing valid and reliable measurement procedures, which allow for a more
comprehensive understanding of self-harm and may aid in improved detection and
treatment.
Purpose and Importance of the Review
Despite the increasing interest in examining self-harm, there is no singularly
accepted paradigm for organizing the literature; explaining existing findings; or even
defining the phenomena of interest. This has resulted in an accumulating literature that
lacks a systematic direction or set of organizing principles.
Numerous impediments have hampered attempts to understand self-harm. The
examination of self-harm by diverse disciplines has produced inherently discrepant and
incomparable results, which have appeared in widely scattered journals ranging from
criminology to plastic surgery (Feldman, 1988). Variations in sampling, research
approach, assessment instruments, and operationalization of the construct of self-harm
have resulted in inconsistent and sometimes contradictory research findings (Nock &
Prinstein, 2004b).
Overall, the measurement of self-harm is a poorly developed field and as a result
the scope of research on self-harm is limited. For instance, the failure of the field to move
beyond purely descriptive and correlational studies of self-harm has resulted in limited
information regarding what factors initiate and maintain self-harm (Nock & Prinstein,
2004b). In addition, few instruments exist that examine the context or functions of self-
harm, which are integral to understanding why people self-harm. Further complicating
matters is a poorly defined nomenclature and the use of a wide-range of instruments with
unknown psychometric properties. Arensman et al. (2001) and Hawton et al. (1998)
conducted meta-analytic reviews of the self-harm treatment outcome studies and
identified that behaviors were inconsistently defined, different types of outcome
measures were used, and when similar measures were employed, they were often
recorded differently. They noted that the inconsistency of outcome measurement is a
significant impediment to developing effective service provisions for deliberate self-harm
patients (Arensman, et al.; Hawton, et al.). As successful treatment of self-harming
patients is predicated upon the accurate evaluation of factors such as lethality and
severity, the clinical relevance of accurate assessment is high. Improved standards of
measurement have the potential to advance our understanding and treatment of deliberate
self-harm. It has been suggested that collaboration among researchers might result in the
development of standards for measuring deliberate self-harm (Arensman, et al.; Hawton,
et al.). In an effort to encourage collaboration, the following review systematically
describes and evaluates from a conceptual and psychometric standpoint the most
common instruments used to measure deliberate self-harm behavior.
Summary
Given the clinical relevance of self-harm and the necessity of continuing research
in this area, a detailed description and critique of instruments used in its measurement is
needed. The uses of systematic reviews in psychosocial research are invaluable given the
difficulty in accessing the quality and vast quantity of research studies in ones area of
interest (Peacock & Forbes, 2004). This critical review will provide clinicians and
researchers with relevant information regarding the strengths and weaknesses of the
procedures and instruments upon which informed selection can be made.
The chapter that follows provides a review of the literature regarding deliberate
self-harm including phenomenology, risk factors, clinical correlates, and issues related to
objective assessment and measurement. A comprehensive review of the clinical literature
assists in (a) clarifying the nature and boundaries of the construct, (b) assessing the
operationalization of the construct, and (c) identifying existing problems with assessment
(Clark & Watson, 1995; Haynes, Richard, & Kubany, 1995). These three domains will
provide a context from which to make informed and accurate assessments of the validity
of the instruments reviewed. However, as mentioned, much of the development and use
o f such instruments has been undertaken without proper consideration of the impact of
underlying methodological assumptions. Given the centrality of methods of measurement
in interpreting the reliability and validity of research findings, an overview of current
practices in the measurement of deliberate self-harm is provided.
CHAPTER II
REVIEW OF LITERATURE
This chapter presents a review of the empirical and theoretical literature
including: (a) conceptual and operational definitions of deliberate self-harm, (b)
prevalence, (c) phenomenology, (d) known risk factors, (e) diagnostic challenges, and (f)
measurement of self-harm.
Conceptual Issues
Terminology
One significant weakness in the existing literature is the lack of a consistent and
agreed-upon conceptual definition of deliberate self-harm behavior. In fact, problems in
terminology have long hampered research on self-harming behavior (Feldman, 1988;
Gratz, 2001). The purpose of this opening discussion is to provide a definitional and
conceptual understanding of the behaviors investigated within this review.
One source of inconsistency in defining self-harm is that for more than three
decades efforts to develop a taxonomy of deliberate self-harm behaviors has been
thwarted by the use of varied terms used to describe phenomena of interest (Gratz, 2001;
Klonsky, Oltmanns, & Turkheimer, 2003; Pattison & Kahan, 1983). For instance, the
terms focal suicide (Menninger, 1935,1938), parasuicide (Gardner & Cowdry, 1985;
Linehan, 1987), self-wounding (Tantam & Whittaker, 1992), self-cutting (Greenspan &
Samuel, 1989), self-injury (Osuch, Noll, & Putnam, 1999), self-harm (Gratz; Pattison &
Kahan), and self-mutilation (Favazza, 1998; Suyemoto, 1998) all appear in the literature.
The second source o f inconsistency is that these terms have been used to define a wide
spectrum of self-harm behaviors including, but not limited to, “cutting, burning,
swallowing toxic or harmful substances (including cleaning solutions, glass, or pins),
punching or hitting oneself, bone breaking, self-surgery, interfering with wound healing,
pulling out hair, and skin picking” (Croyle, 2000, p. 7). The third source of inconsistency
is that some terms have been used interchangeably to denote the same behaviors (Gratz).
For example, deliberate self-harm, self-injury, and self-mutilation have been used in
several studies (Baral, Kora, Yuksel, & Sezgin, 1998; Brodsky, Cloitre, & Dulit, 1995;
Dulit et al., 1994; Simeon, Stanley, Frances, Mann, Winchel, & Stanley, 1992; Winchel
& Stanley, 1991) to denote the same behavioral phenomena. The fourth source of
inconsistency is that some researchers use the same terms, to denote inherently different
behaviors (Gratz). For example, the term self-harm is generally used to distinguish
between suicide-related and non-suicide-related self-harm behavior; however, not all
researchers make such distinctions (Kerfoot, 1988).
The continued modification of the conceptual definitions underlying specific
terms has resulted in uncertainty in the field regarding what is considered “deliberate
self-harm” and what behaviors fall into other boarder categories such as “self-injurious
behavior” and “suicide attempts.” Moreover, the use of numerous operational definitions
has resulted in the likelihood that different constructs are being measured and reported in
the literature (Gratz, 2001). While issues regarding terminology are potentially
rectifiable, attempts to classify acts of self-harm and thus provide a conceptual definition
have remained controversial.
Attempts at Classification
Categorizing the diverse forms of self-harm behavior has been a challenge for
researchers in the field and several classification systems have been proposed (Favazza &
Rosenthal, 1990; Menninger, 1935,1938; Pattison & Kahan, 1983; Ross & Mckay, 1979;
Walsh & Rosen, 1988). A brief overview of these past classification systems will be
presented to provided a background to the classification used for the purposes of this
study.
The first classification system was developed by Menninger (1935,1938) in
which he defined self-mutilation as a deliberate destructive attack focused upon a specific
part of one’s body. He proposed six broad categories of self-mutilation, each defined by
underlying unconscious drives and their psychic manifestations: (a) neurotic self-
mutilation (unnecessary surgery, disfiguring hair removal, skin picking, nail biting); (b)
religious self-mutilation (represented sacrifice and atonement for sins); (c) puberty rites
(hymen removal, clitoral alteration, circumcision); (d) psychotic self-mutilation (genital
self-mutilation, eye enucleation, limb amputation); (e) self-mutilation in organic diseases;
and (f) self-mutilation in normal people: customary and conventional forms (trimming of
hair, shaving, nail clipping).
In terms of psychodynamic determinants, Menninger (1935, 1938) based his
categorization of self-mutilation on Freud’s tripartite model of the mind, which posited
the unconscious drives of the id against the superego’s societal injunctions, resulting in a
compromise formation enacted by the ego. While Menninger’s comprehensive and multi
dimensional nosology was groundbreaking in its significance to the field (Favazza 1998;
Walsh & Rosen, 1988), several problems existed. First, he was criticized for being
speculative in regard to psychodynamic determinants of self-mutilation. Second, the
categories suggested are not mutually exclusive. Thirdly, referring to common culturally
acceptable practices, such as everyday grooming practices, was questionable (Walsh &
Rosen).
Pattison and Kahan (1983) combined three major variables from the literature on
self-harm and created a comprehensive model distinguishing between suicidal acts and
self-harmful acts. The variables of interest consisted of (a) a direct/indirect variable
(representing differences in time and awareness of behavior), (b) a lethality variable
(representing a continuum of high to low probability of death), and (c) a repetition
variable (representing single-event versus multiple-event classes of behavior); (Pattison
& Kahan). All forms of potential self-damaging behavior, including drug use and suicide
attempts were divided into one of six categories. Based on their classification system,
they proposed a separate diagnosis for “deliberate self-harm,” which was distinguished
by direct self-harm behavior, with low lethality, in a repetitive pattern (Pattison &
Kahan). O f particular interest is the exclusion of suicide attempts and drug overdoses
from this definition of self-harm.
Walsh and Rosen (1988) proposed the next attempt at classification. Rather than
create a formal nosology or typology, they devised a heuristic schema that suggests,
“there is a rather wide spectrum of human behavior that entails the alteration of physical
appearance and body configuration” (Walsh & Rosen, p. 6). Four types of “self-alteration
of physical form” were included in their schema. They proposed that what distinguishes
between self-mutilative (Types III and IV) and non self-mutilative (Types I and II) forms
of physical alteration of body form were the interrelated dimensions of (a) physical
damage, (b) psychological state at the time of the self-altering act, and (c) the social
acceptability of the behavior (Walsh & Rosen). All three dimensions had to be in some
sense deviant for a behavior to be distinguished as self-mutilative. Type I behaviors, such
as ear piercing, were not considered self-mutilation as the physical damage is superficial
to mild, the psychic state at the time of the act is benign, and the social acceptability of
the behavior is broad. Type II self-alterations, such as piercing and ritualistic scaring,
while more damaging, tend to be considered beauty enhancing or symbolic and are, thus,
not considered self-mutilative. Type III behaviors, such as wrist cutting, are considered
self-mutilative as the physical damage is mild to moderate, the psychic state is one of
crisis, and the social acceptability is limited. Type IV behaviors, such as amputation,
autocastration, and self-enucleation, are considered both self-mutilative and pathological
as the damage is severe, the psychic state at the time of the incident is usually one of
psychotic decompensation, and the social response of others is one of condemnation
(Walsh & Rosen).
The most widely accepted classification system for “self-mutilation” was initially
developed by Favazza and Rosenthal (1990). They define self-mutilation as the
deliberate, direct destruction or alteration of body tissue without conscious suicidal
intent. Culturally sanctioned forms of self-mutilation were differentiated from
pathological forms of self-mutilation. Pathological self-mutilation was subdivided into
three categories “based on the degree of tissue destruction and the rate and pattern of
behavior” (Favazza, 1998, p. 263). These categories include major, stereotypic, and
superficial/moderate. Favazza notes that each type of self-mutilation is either a central
diagnostic criterion or an associated feature of certain mental disorders.
10
Major self-mutilation refers to infrequent acts such as eye enucleation, castration,
and limb amputation (Favazza). These behaviors are most commonly associated with
features of psychosis (depression, mania, schizophrenia, acute psychotic episodes) and
acute intoxication (Favazza & Rosenthal, 1993).
Stereotypic self-mutilation “refers to acts such as head banging and hitting, orifice
digging, arm hitting, throat and eye gouging, self-biting, tooth extraction, and joint
dislocation” (Favazza, 1998, p. 264). These behaviors are typically characteristic of
mentally retarded persons and tend to have a rhythmic quality that appears to be devoid
of symbolism. They typically present as a symptom or associated feature of Tourettes
syndrome, neurocanthosis, Retts’ disorder, Lesch-Nyhan syndrome, autism,
schizophrenia, and acute psychosis (Favazza; Favazza & Rosenthal, 1993).
Superficial/moderate self-mutilation is the most common self-destructive
behavior. The superficial/moderate category is further subdivided into three subtypes:
compulsive, episodic, and repetitive. Trichotillomania, nail biting, and skin picking are
the most studied types of compulsive/superficial self-mutilation (Favazza, 1998). The
behavior is commonly automatic and is not considered to be under the conscious control
of the individual. The second superficial subtype is the episodic self-mutilation. The most
common form of this subtype is skin cutting and burning. This subtype is often an
associated feature in a number of disorders such as borderline, histrionic, and antisocial
personality disorders, posttraumatic stress disorder, dissociative disorders, and eating
disorders (Favazza). The third subtype of superficial self-mutilation is repetitive self-
mutilation. Episodic self-mutilation becomes repetitive self-mutilation when the self-
harming behaviors become an overwhelming preoccupation. According to Favazza, these
11
individuals identify as “cutters” or “burners” (although multiple methods are common)
and report being addicted to self-harm. Similar to Pattison and Kahan (1983), Favazza
excludes drug overdoses and suicide attempts from his definition of self-mutilation.
Conceptual Definition
The above classification systems have all added conceptual pieces to the puzzle of
delimiting and defining self-harming behaviors. Several dimensions have been found
useful when attempting a definition including: (a) intentionality, (b) social acceptability,
(c) suicidal intent, and (d) level of physical damage (Pattison & Kahan, 1983; Walsh &
Rosen, 1988). Gratz (2001) suggests one way to synthesize the aforementioned literature
is to use the term “deliberate self-harm” to denote the episodic/repetitive forms of
superficial-moderate self-mutilation categorized by Favazza (1998). Thus, deliberate self-
harm is defined as “the deliberate, direct destruction or alteration of body tissue without
conscious suicidal intent, but resulting in injury enough for tissue damage (e.g., scarring)
to occur” (Gratz, p. 254). This definition includes the above-mentioned dimensions, yet
excludes socially accepted means of self-harm and self-harm by overdose. The term
deliberate self-harm will be used throughout this study except when the body of another
author’s work is cited within this review, in which case, their terminology will be used.
Prevalence of Self-Harm
The determination of an exact prevalence of self-harm is exceedingly difficult due
to several factors including: (a) relevant research is reported in diverse journals such as
criminology and plastic surgery; (b) self-harm behaviors are sometimes included within
the broader categories of self-injury, self-mutilation, or suicide; (c) few systematic
epidemiological studies of self-harm exist and they tend to be either over-inclusive or
12
under-inclusive with regard to self-harm behaviors; and (d) individuals who engage in
self-harm behavior do so in private and are secretive of its existence (Feldman, 1988;
Walsh & Rosen, 1988). Thus, the prevalence of self-harm can only be estimated.
Recent estimates of the prevalence of self-harm within the general population
vary in their numbers, but all conclude that self-harm behaviors are seriously
underreported (Favazza, 1987,1989; Simpson, 1975; Walsh & Rosen, 1988). Walsh and
Rosen reported that in their examination of epidemiological studies, the best range they
could come up with was between 14 and 600 persons per 100,000 per year. This means
that in 1988, there were 240 million people in the United States and anywhere from
33,600 to 1,440,000 people self mutilated themselves during a given year. Welch (2001)
estimated that lifetime prevalence of self-harm ranges from 720 to 5,930 per 100,000 in
the general population. The incidence of self-harm within psychiatric populations is much
higher and rates have been estimated to range between 4% and 20% of all psychiatric
inpatients (Favazza & Conterio, 1988; Feldman, 1988; Suyemoto, 1998).
Characteristics of Self-Harming Populations
Providing an all-inclusive description of self-harm and estimating the prevalence
of self-harm in the general population is impossible. However, the following general
statements can be made regarding inpatients that self-harm based on the body of research
that exists. First, while estimations vary, self-harm typically occurs more frequently
among single women (Carroll, Shaffer, Spensley, & Abramowitz, 1980; Favazza &
Conterio, 1988; Favazza, DeRosear, & Conterio, 1989; Graff & Maliin, 1967; Herpertz,
1995; Novotny, 1972; Pao, 1969; Romans, Martin, Anderson, Herbison, & Mullen, 1995;
Simpson, 1975). It has been suggested that the estimates of prevalence ratios range from
13
2 to 1 to as many as 20 to 1, women to men, depending on the specific behavior studied
(Ross & Heath, 2002). Second, the age at which the first episode of self-mutilation occurs
is usually in middle to late adolescence (Favazza & Conterio; Feldman, 1988; Herpertz;
Rosenthal et al., 1972; Suyemoto & MacDonald, 1995). Pattison and Kahan (1983)
analyzed 56 published case reports and found that the average age was 23 years of age.
Thirdly, in spite o f equivalent education those who engage in self-harm are often
underemployed, with lower vocational achievement than controls (Favazza & Conterio;
Herpertz).
Phenomenology of Self-Harm
An amazing amount of agreement exists among the phenomenological accounts
o f self-harm (Suyemoto, 1998). A fairly consistent chain of events follows in these
patients, regardless of the actual precipitant, which typically take the form of
abandonment, threats of abandonment, loss of a meaningful person, or an impasse in
interpersonal relations either in reality or fantasy (Feldman, 1988; Novotny, 1972;
Rosenthal et al., 1972; Simpson 1975). Walsh and Rosen (1988) characterized the chain
of events as consisting of the following: “(1) the loss or threatened loss of a significant
relationship; (2) mounting, intolerable tension that the individual is unable to verbalize;
(3) a state o f dissociation or depersonalization; (4) an irresistible urge to cut; (5) the
performance o f the act, usually without pain; (6) tension relief and a return to normality”
(p. 41-42). It should be noted that the relief these individuals obtain is often followed by
overwhelming feelings of self-hatred, disappointment, and fear of consequences for the
act (Feldman).
14
While self-harm “involves numerous episodes and a variety of methods, including
cutting, burning, slashing, banging, picking, and bone breaking” (van der Kolk et al.,
1991, p. 1665), the most commonly studied form is that of self-cutting. Self-harm in the
form of self-cutting has been inflicted on virtually every part of the body. Feldman
(1988) reports that the face, wrists and forearms, hands and fingers, abdomen, thighs,
genitals, breasts, umbilicus, Achilles tendon and soles of the feet have all been cut by
patients. However, the arms are the most frequently cut, given the ease with which the
wounds can be concealed or shown (Feldman).
The range of items utilized in self-harm speaks to the morbid resourcefulness of
these individuals (Feldman, 1988). In addition to razor blades and knives, fingernail
fragments, bones from food, strands of hair, staples, and pins have been identified in the
literature (Novotny, 1972). Often these cutting objects hold some symbolic meaning or
serve as transitional objects by the patients and are thus hidden and coveted (Podovoll,
1969).
Functions of Self-Harm
While theoretical explanations regarding the usefulness of self-harm are
numerous, we continue to lack a clear understanding of what psychological functions
deliberate self-harm serves (Suyemoto, 1998). Osuch et al. (1999) noted that
“experimental data on the phenomenology of SIB in the psychiatric population is limited”
(p. 335). Empirical investigation of this facet of deliberate self-harm is imperative as
understanding the psychological functions of deliberate self-harm is vital to effective
treatment o f these individuals (Himber, 1994). However, several clinicians have
identified the possible explanations for this perplexing behavior.
15
Carr (1977) reviewed the existing literature and noted that five major hypotheses
regarding motivation for self-harm existed. These included: (a) positive reinforcement
hypothesis, (b) negative reinforcement hypothesis, (c) self-stimulation hypothesis, (d)
organic hypothesis, and (e) psychodynamic hypotheses. Carr noted that effective
treatment might depend on the recognition of different motivational factors involved.
Simpson (1975) interviewed 24 patients seen in a psychiatric emergency room with
special reference to the phenomenology o f the act of cutting. Reported motivations for
self-mutilation included: (a) tension release, (b) reintegration-repersonalization, (c) anger
expression, and (d) affect modulation. Similarly, in a sample of 54 female psychiatric
inpatients, Herpertz (1995) found that the most common explanations for self-harm
included tension release, expression of anger or revenge, longing for care and attention,
self-hatred and self-punishment. More recent investigations into the underlying
motivation for self-harm have opted for interview methodologies to assess motivation.
Favazza (1989) utilizing the Self-Harm Behavior Survey (SHBS) examined the self-
reports of 300 nonpsychotic patients. His findings resulted in 12 explanations for self-
mutilation, which included: (a) tension release, (b) return to reality, (c) establishing
control, (d) security and uniqueness, (e) influencing others, (f) negative perceptions, (g)
pressure from multiple personalities, (h) sexuality, (i) euphoria and titillating, (j) venting
anger, (k) relief from alienation, and (1) irresistible urges. Favazza concluded that as no
precise, common pathway or trigger for self-mutilation exists no single explanation can
be applied to all patients.
Working from the belief that self-harm is a multidetermined phenomenon and that
as such it can serve multiple simultaneous functions, Suyemoto (1998) proposed the most
16
comprehensive theoretical explanation to date. She formulated six functional models to
describe deliberate self-harm, each derived from various theoretical positions including
behavioral, systemic, psychoanalytic, ego psychological, self-psychological and object
relations. These models include: (a) environmental, (b) anti-suicide, (c) sexual, (d) affect
regulation, (e) dissociation, and (f) boundaries models. While the authors clearly admit
that completely differentiating one function from another is difficult, they note that an
attempt to do so is "necessary to aid our understanding of the behavior and begin to tease
apart the particular reasons particular patients engage in this behavior" (Suyemoto, p.
537).
Foundations of Deliberate Self-Harm
Given the multidetermined nature of self-harm, the ability to identify one specific
etiological event is likely impossible. To date, empirical research on risk factors for self-
harm have closely examined traumatic childhood experiences.
Childhood Physical Abuse
Empirical studies examining the relationship between self-harm and childhood
physical abuse have provided mixed evidence. Early studies of self-harm and child
physical abuse have linked the two constructs (Green, 1978, Grunebaum & Klerman,
1967), noting that physically abused children engage in significantly more self
destructive behavior (including deliberate self-harm). Similarly, Carroll et al. (1980)
found that self-harming patients reported physical abuse strikingly more often than
control subjects did (p < .005). Similarly, Gratz, Conrad, and Roemer (2002) found a
zero-order relationship (r = .26, p < .05) between physical abuse and self-harm among
female college students.
17
However, when the unique relationship between child physical abuse and self-
harm is examined, it appears that other factors account for more of the variance in self-
harm than childhood physical abuse. The aforementioned study by Gratz et al. (2002)
found that when the impact of other potential risk factors are controlled for childhood
"physical abuse did not contribute uniquely to the prediction of self-harm among female
college students, possibly because of the strong association found by the authors between
physical and sexual abuse" (p. 196). Given the mixed results, the possibility that
childhood physical abuse may be a risk factor for later self-harm, it should not be ruled
out.
Childhood Sexual Abuse
There is a preponderance of evidence that suggests a strong relationship between
childhood sexual abuse and self-harm (Gratz et al., 2002; Lipschitz, Winegar, Nicolaou,
Hartnick, Wolfson, & Southwick, 1999; van der Kolk et al., 1991; Zlotnick, Shea,
Pearlstein, Simpson, Costello, & Begin, 1996). The following studies examined zero-
order correlations between self-harm and sexual abuse, van der Kolk et al. examined the
relationship between self-harm behavior and three different forms of childhood abuse
(sexual, physical, and neglect) in a mixed clinical-community sample of men and women.
They found that sexual abuse was more strongly related to self-harm than either physical
abuse or witnessing domestic violence, van der kolk et al. noted that there is clear
evidence that childhood histories of trauma are present in the overwhelming majority of
self-harmers. Similarly, Zlotnick et al. found that rates of sexual abuse among female
inpatients with histories of self-harm were significantly higher than those without
histories o f self-harm. Similarly, Lipschitz et al. studied female and male inpatient
18
adolescents and found that sexual abuse was a significant predictor of whether the
participant who self-harms can be separated from those adolescents who did not engage
in this behavior.
Given that the relationship between self-harm and childhood sexual abuse could
be mediated by some third variable (e.g., emotional neglect, dissociation), recent studies
have examined the relationship while controlling for the impact of other potentially
distressing childhood experiences. Boudewyn and Liem (1995) examined the relationship
between childhood sexual abuse and self-harm in a college student sample while
statistically controlling for several potentially distressing childhood experiences (e.g.,
separation, loss, physical abuse, emotional neglect, and sexual abuse). They found that
52% of the individuals with a history of deliberate self-harm, had been sexually abused as
children. Furthermore, when all variables measured were entered into a regression
equation, only childhood sexual abuse emerged as a significant predictor of self-harm.
This provides some evidence for its unique relationship to self-harm. Similarly, Gratz et
al. (2002) examined the unique predictive value of childhood sexual abuse, childhood
physical abuse, childhood separation, maternal and paternal emotional neglect, insecure
maternal and paternal attachment, and dissociation. They found that when all other
factors were statistically controlled, sexual abuse remained a significant predictor o f self-
harm among women.
Neglect
Several studies have examined the role of neglect as a risk factor for deliberate
self-harm. Lipschitz et al. (1999) found that emotional neglect was more strongly
associated with self-harm than physical abuse or physical neglect. When all five risk
19
factors measured (i.e., sexual abuse, physical abuse, emotional abuse, physical neglect,
and emotional neglect) were entered into a logistic regression analysis, only sexual abuse
and emotional neglect were significant predictors of whether the adolescent inpatients in
their study who engage in self-mutilation could be separated from those participants who
did not engage in this behavior. Similarly, Dubo, Zanarini, Lewis, & Williams (1997)
delineated between physical and emotional neglect and found that among a sample of
inpatients, emotional neglect was the strongest predictor of deliberate self-harm (when
controlling for childhood sexual abuse and physical abuse), whereas physical neglect was
not a significant predictor of deliberate self-harm.
However, Gratz et al. (2002) found that among a sample of college females that
both physical and emotional neglect were significant predictors of deliberate self-harm.
Despite mixed results, the potential relationship between self-harm and neglect warrants
continued examination as there is some evidence that childhood neglect (both emotional
and physical) may have serious negative consequences for later ego control.
Diagnostic Challenges of Self-harm
Self-harm has been associated with numerous diagnostic categories, several
clinical syndromes, as a variant of suicide, and as a unique disorder. The following
section will present the empirical evidence regarding several frequently cited obstacles to
the diagnostic clarity of self-harm.
Differentiation from Suicide
Although self-harm has been viewed in the past as a variant o f suicidal behavior
(Gardner & Cowdry, 1985), it is now widely accepted that self-harm exists as a unique
clinical phenomenon distinct from suicide (Favazza, 1998; Lipschitz et al., 1999;
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Shneidman, 1973; Walsh & Rosen, 1988). The most comprehensive delineation between
suicide and self-harm was proposed by Walsh and Rosen, in which they compared the
two behaviors on ten common characteristics. The first characteristic compared was that
of the stimulus for the act. In suicide, the stimulus appears to be escape from
unendurable, unacceptable psychological pain; whereas for self-mutilation, the stimulus
is an escalating, intermittent psychological pain. The second characteristic is that of the
stressor for the act. Shneidman (1985) explains that suicide results from needs that are
thwarted or unfulfilled over long periods; whereas in self-mutilation, while psychological
needs are frustrated, the frustration is related to short-term delays of needs. The third
characteristic is that of purpose. For suicidal patients, the act is the ultimate solution to
their problem; whereas for self-mutilators, the act is a short-term alleviation of the
problem. The fourth characteristic is that of the goal. In suicide, the goal is cessation of
consciousness, whereas in self-mutilation, the goal is an alteration in consciousness. The
fifth characteristic is that of emotion. In suicidal patients, the emotion is that of
hopelessness or helplessness; whereas in self-mutilation, the feeling is one of alienation.
Self-mutilators feel both intrapersonally and interpersonally alienated (Grunebaum &
Klerman, 1967; Pao, 1969; Podvoll, 1969; Ross & McKay, 1979). The sixth
characteristic is that of internal attitude. In suicidal patients, the internal attitude is one of
ambivalence between wishing for death and hoping to be rescued; whereas for self-
mutilating patients, the attitude is one of resignation to pain as a relief of psychological
tension. The seventh characteristic is that of cognitive state. In suicides, the cognitive
state is one of constriction, where thought is typically dichotomous. In self-mutilation,
the individuals are typically experiencing dissociation or depersonalization; thus, their
21
cognitive state can be described as fragmented or scattered. Hence, they often have
problems rationally deciding how to relieve tension. The eighth characteristic is that of
the interpersonal act. With individuals who commit suicide, they typically communicate
their intent prior to acting. This communication is believed to indicate their ambivalence
regarding the act. In self-mutilation, the intent to act is rarely communicated until after
the act. The act itself, not the intent to act, wields tremendous power within relationships,
and, hence, can often be seen as an act of coercion or manipulation. The ninth
characteristic is that of the action committed. In suicides, the act is focused on escaping
the feelings of unendurable pain and feelings of hopelessness-helplessness; whereas in
self-mutilation the act serves to reintegrate the person. The reintegration is composed of
an interpersonal component in which the tension is reduced, thus, terminating the state of
dissociation or depersonalization. In addition, there exists an intrapersonal component, in
which the person effectively re-involves themselves in their social network. The tenth
and final characteristic is that of consistency. For suicides, the act is “not an anomaly; the
suicide is an extension of the person’s general coping mechanisms, cognitive and
affective styles, and lifelong behavioral patterns” (Walsh & Rosen, 1988, p. 50). In self-
mutilation, as with suicide, the act is consistent with the patterns of an individual’s life.
However, in self-mutilation, the coping mechanism, no matter how limited, is adaptive in
sustaining life.
While the apparent similarities between suicide and deliberate self-harm can
appear substantial, when they are compared on their most general characteristics that they
are very different behaviors (Walsh & Rosen, 1988). The misdiagnosis or mislabeling of
deliberate self-harm as a suicidal gesture often leads to unnecessary psychiatric
22
hospitalizations and inappropriate interventions (Walsh & Rosen). However, it is
important to remember that for some individuals, self-harm escalates to suicidality, as
such, careful monitoring of a patients behavior and intent are paramount.
Clinical Correlates
The current Diagnostic and Statistical Manual of Mental Disorders, Fourth
Edition, Text Revision (DSM-IV-TR; American Psychiatric Association, 2000) considers
self-harm to be characteristic of, or related to, one of three disorders. It is considered an
essential feature of Impulse Control Disorders Not Elsewhere Classified, it is a diagnostic
criterion for Borderline Personality Disorder, and it is an associated descriptive feature of
Posttraumatic Stress Disorder (DSM-IV-TR). However, the clinical research shows that
self-harm was in fact found to correlate with numerous clinical disorders including:
eating disorders (Dulit et al., 1994; Farber, 2002; Shearer, 1994; Simpson 1975);
dissociative disorders (Coons & Milstein, 1990; Shearer; Zlotnick et al., 1996);
obsessive-compulsive traits (Simeon, Stein, & Hollander, 1995); substance abuse
(Simpson; Shearer; van der Kolk, & Fisler, 1993; Zlotnick et al., 1999); passive
aggressive, schizoid, and avoidant personality styles (Haines, Williams, & Brain, 1995);
antisocial personality disorder (Zlotnick et al., 1999); alexithymia (Zlotnick et al., 1996);
and major affective disorders (Farber). As a result, several researchers have suggested
that self-harm, as a behavioral phenomenon comprises its own disorder (Klonsky et al.,
2003). However, when psychotic and developmentally delayed populations are excluded,
the most common psychiatric disorders associated with repetitive self-harm are
dissociative disorders, borderline personality disorders, and eating disorders.
23
Dissociation
Given that sexual abuse, physical abuse, and neglect are implicated in the etiology
o f self-harm, as well as dissociation and the similarity in the phenomenological
descriptions of both behaviors, it is not unusual that research has supported an association
between deliberate self-harm and dissociation (Brodsky et al., 1995; Graff & Mallin,
1967; Gratz et al., 2002; Herpertz, 1995; Kisiel & Lyons, 2001; Pao, 1969; Rosenthal et
al., 1972; Shearer, 1994; Simpson 1975; van der Kolk et al., 1991; Zlotnick et al., 1996;
Zlotnick et al., 1999). However, the nature of that relationship is complex and far from
definitive within the literature. Putnam (1997) put forth a hierarchical model of
dissociation in which primary dissociation (e.g., forgetfulness, fragmentation, emotional
numbing) serves as a mediator to several symptom constellations (e.g., mood swings,
aggressive behavior, substance abuse). This model was tested by Kisiel and Lyons with
adolescents, and they found that dissociation was independently associated with several
types o f risk-taking behavior (i.e., suicidality, self-mutilation, and sexual aggression).
Analysis of covariance indicated that dissociation had an important mediating role
between sexual abuse and psychiatric disturbance.
The classic theory of dissociation set forth by Janet (1901/1977,1920/1965, as
cited in Scroppo, Weinberger, Drob, & Eagle, 1998) still predominates our thinking about
dissociation. This theory states, “in response to trauma, dissociatively disordered patients
develop a set of characteristic psychological process that serve to keep some experiences
out of conscious integration with the bulk of mental life” (p. 273). Memories and affects
related to trauma are encoded during these altered states (Lowenstein, 1994), and when
the person returns to a non-dissociative state, there is less availability to the dissociated
24
material. While mild dissociation can feel strange, more severe forms can be painful and
can manifest in feelings of depersonalization or derealization. While the numbness of
these experiences protects the individual from intolerable emotional stress, the
separateness and deadness are themselves unbearable (Hyman, 1996).
Longstanding symptoms of dissociation are likely to lead to the experience of
deadness, disintegration, or fears of bodily dissolution. Research and clinical experience
have led several authors to conclude that self-harm is often used primarily as a grounding
technique when one experiences the threat of fragmentation, disintegration, and
devouring annihilation (Brodsky et al., 1995; Favazza, 1989; van der Kolk et al., 1991).
Paradoxically, the experience of dissociation actually enables self-wounding to occur
(Tantam & Whittaker, 1993) as it accounts for the individual’s relative numbness or
anesthesia during the act (Favazza, 1987; Gardner & Cowdry, 1985; Ross & McKay,
1979; Zlotnick et al., 1996). However, it has been alternately suggested that for some
individuals a dissociated state may be the desired result of the self-injury. The
achievement of such a state would allow the self-injurer cognitive and emotional distance
from the initial stressor (Farber, 2002; Gratz et al., 2002). van der Kolk and McFarlane
(1996) note in order to regain control over problems with affect regulation, traumatized
people will employ a variety of methods, including intentionally induced dissociation.
Eating Disorders
The coexistence of deliberate self-harm and eating disorders is frequently
mentioned in the psychiatric and psychoanalytic literature (Asch, 1971; Farber, 2002;
Favazza, 1989; Favazza et al., 1989; Rosenthal et al., 1972; Paul, Schroeter, Dahme, &
Nutzinger, 2002; Simpson & Porter, 1981; Siomopoulos, 1974). In fact, numerous
25
researchers have suggested eating disorders and self-harm are likely different
manifestations of the same pathological process (Carroll et al., 1980; Dulit et al., 1994;
Walsh & Rosen, 1988), and that in impulsive clients, the addictive behaviors of self-
harm, substance abuse, and disordered eating are interchangeable (Conterio & Lader,
1998; Favazza; Miller, 1994). It has been estimated that as many as 50% of female
chronic self-mutilators have a history of anorexia nervosa or bulimia (Favazza, 1987, p.
206).
Bulimia nervosa in particular was found to have a significant relationship with
deliberate self-harm in general. Favazza and Conterio (1989) examined 240 females who
engaged in self-harm. O f this sample, over 50% reported a history of an eating disorder
(22% bulimia nervosa, 15% anorexia nervosa, 13% both bulimia and anorexia nervosa,
11% obesity). Farber (2000) found that 61 of the 99 women (62%) participating in her
study reported engaging in self-harm behavior following a binge-purge cycle. The
frequency with which self-harm and binge-purge behavior coexisted was assessed and it
was found that 2 participants reported that this occurred on one occasion, 31 reported that
it occurred a few times, 24 reported it occurred numerous times, and 4 reported that it
occurred every time (Farber). Paul et al. (2002) assessed the lifetime and 6-month
occurrence of self-harm behavior in 376 inpatients with eating disorders. They found that
the lifetime occurrence of self-harm was 34.6% and that the highest rates of self-harm
were found in patients with diagnoses of eating disorders not other wise specified
(35.8%) and bulimia nervosa (34.3%).
Eating disordered behavior and self-harming behavior not only frequently co
exist, but also have clear demographic and phenomenological similarities (Cross, 1993).
26
It has been found that eating disorders and self-harm behaviors are more highly prevalent
in women than in men and are often secretive in nature. In addition, both eating
disordered and self-harming individuals feel a compulsive need to engage in self
destructive behavior. Cross noted that both eating disordered and self-harming behaviors
serve affect regulation functions in that they help to modulate and relieve states of
anxiety, sexual tension, anger, or dissociated emptiness.
Borderline Personality Disorder
The presence of self-harm is often equated with a diagnosis of Borderline
Personality Disorder (BPD). One reason for the synonymous nature of BPD and self-
harm is that one diagnostic criteria for BPD relates directly to self-harm, “recurrent
suicidal behavior, gestures, or threats, or self-mutilating behavior” (American Psychiatric
Association, p. 654). The literature on self-harm has focused almost exclusively on self-
harm in personality disorders, especially BPD. It has been estimated that up to 80% of
individuals with diagnoses of BPD report histories of self-harm (Shearer, Peters,
Quaytman, & Wadman, 1988). In fact, the existence of many shared characteristics (i.e.,
feelings of emptiness, rapidly fluctuating mood swings, poor response to psychotropic
medications, psychotic episodes which are not characteristic of other psychotic disorders,
poor object relations, poor impulse control, and other forms of impulsive, self-destructive
behavior) between patients with borderline personality disorder and patients who self-
harm provided the impetus for including self-destructive acts in the diagnostic criteria for
BPD (Schaffer, Carroll, & Abramowitz, 1982). Deliberate self-harm behavior within the
context o f BPD exists along a continuum from severe to milder forms of self-harm better
27
characterized as self-defeating (Castillas & Clark, 2002; Clark, 1993; Sansone,
Wiederman, & Sansone, 1998).
Studies have suggested that the presence of self-harm in patients with diagnoses
of BPD might serve as a marker for more severe borderline character pathology (Simeon
et al., 1992). However, these researchers also found that the unique combination of
“impulsivity and aggression and the variety of personality disorders characteristic of the
self-mutilator group raise the argument that self-mutilation might be best viewed as a
distinct Axis I impulse control disorder” (Simeon et al., p. 225). In addition, some
researchers have questioned the value of combining self-harm under the broad diagnostic
categories such as personality disorders, as this inclusion has done little to enhance the
understanding of the phenomenon (Bennum, 1983).
Deliberate Self-Harm as a Distinct Syndrome
The fact that deliberate self-harm occurs across a variety of diagnoses has raised
the question of whether it should be investigated as a behavioral phenomenon in its own
right, rather than a symptom of another disorders (Klonsky, et al., 2003). Several
researchers (Favazza & Rosenthal, 1993; Lacey & Evans, 1986; Pattison & Kahan, 1983;
Pao, 1969; Rosenthal et al., 1972) have attempted to classify self-harm as a distinct
diagnosis. For instance, Pao suggested a syndrome of deliberate self-cutting; Rosenthal et
al., a wrist-cutting syndrome; Pattison and Kahan, the deliberate self-harm syndrome; and
Favazza and Rosenthal, a syndrome of repetitive self-mutilation.
The impulsive nature of self-harm is most often the impetus for consideration as a
separate diagnosis. Walsh and Rosen (1988) note, “in most instances, self mutilation is an
impulsive act. As such, it is one component of the overall impulsive style...” (p. 70).
28
Studies o f the clinical correlates of self-mutilation have revealed that impulsive behavior
in numerous forms is strongly related to self-mutilation (Zlotnick et al., 1996). Lacey and
Evans (1986) have raised the idea of self-mutilation being one of numerous behaviors
that are characterized by a lack of impulse control and have called for a separate
diagnosis of multi-impulsive personality disorder (Lacey & Evans). They note that
numerous clinical problems are related to a lack of impulse control and that if one cuts
across the current diagnostic system, a pattern of impulsivity among numerous patients is
evident. They describe the interchangeable nature of a cluster o f symptoms including
bulimia, kleptomania, depression, self-mutilation, and substance abuse (Lacey & Evans).
However, the most compelling and comprehensive of these theories of self-harm as a
distinct disorder, have been suggested by Pattison and Kahan (1983) and Favazza and
Rosenthal (1993).
Pattison and Kahan (1983) conducted an exhaustive review of the literature and
outlined what they termed the “deliberate self-harm syndrome” (p. 871). They excluded
suicide attempts and drug overdoses and focused specifically on deliberate self-harm
behaviors, which were low in lethality, involved a direct intentional act, and involved
multiple episodes. They determined that their proposed Deliberate Self-harm Syndrome
met the DSM-III diagnostic criteria for disorder of impulse control not elsewhere
classified, in that it is characterized by a failure to resist an impulse, increasing tension
before committing the act, and experience of pleasure, gratification, or release at the time
of committing the act. They further note the “disorders of this class frequently appear in
the absence of any other mental disorder” (Pattison & Kahan, p. 872). They
29
unsuccessfully attempted to have the Deliberate Self-harm Syndrome included in the
DSM-IV.
Similarly, Favazza and Rosenthal (1990, 1993) unsuccessfully proposed that
repetitive self-mutilation should be regarded as a distinct Axis I impulse disorder.
Following the DSM format for impulse control disorder, Favazza and Rosenthal (1993)
proposed the following diagnostic criteria for repetitive self-harm. Criteria A:
preoccupation with harming oneself physically; Criteria B: recurrent failure to resist
oneself physically, resulting in the destruction or alteration of body tissue; Criteria C:
increasing sense of tension immediately before the act of self-harm; Criteria D:
gratification or a sense of relief when committing the act of self-harm; and Criteria E: the
act of self-harm is not associated with conscious suicidal intent and is not in response to a
delusion, hallucination, or transsexual fixed idea, or serious mental retardation.
The most common objections to distinguishing a distinct diagnostic self-harm
category have been based on the contention that self-harm is merely a comorbid symptom
of differing Axis I and II psychopathology. Gunderson and Zanarini (1987) note that the
diagnostic criteria for BPD include symptoms of many Axis I disorders (e.g., panic
disorder, substance abuse, gender identity disorder, factitious disorders, disorders of
impulse control, attention deficit disorder, and eating disorders). However, Favazza and
Rosenthal (1993) note that given the coexistence of so many o f these Axis I disorders
with BPD, the diagnosis of a concurrent disorder separate from BPD often depends on
the quantity of the symptoms in questions (Favazza & Rosenthal). They suggest that
while occasional self-harm might be consonant with a diagnosis of BPD, a pattern of
frequent uncontrolled repetitive episodes may warrant a separate diagnosis. In addition,
30
numerous researchers have noted that individuals with impulse control deficits
interchangeably engage in numerous pathological acts (kleptomania, substance abuse,
eating disorders, and self-harm); and that they are more likely to be identified as having
Axis II diagnoses such as antisocial, borderline, or histrionic personality disorders
(Brodsky et al., 1995; Castillas & Clark, 2002; Lacey & Evans, 1986; Shearer, Peters,
Quaytman, & Wadman, 1988; Zweig-Frank, Paris, & Guzder, 1994a).
Measurement of Deliberate Self-Harm
Rapid fluctuations in the field regarding terminology and conceptual definitions
of self-harm have clearly hampered the development of valid and reliable assessment
instruments (Feldman, 1988, Gratz, 2001). This has led to significant confusion within
the field (Gratz). To date relatively little attention as been paid to developing measures of
deliberate self harm (Sansone et al., 1998). As such, there are relatively few published
self-harm instruments and none that have been standardized (Gratz; Simeon et al., 1992;
Zlotnick et al., 1996). However, given the prevalence, clinical importance, and role of
self-harm in diagnosing BPD, the development of psychometrically sound assessment
tools is critical (Sansone et al.). A number o f clinically oriented instruments have been
used to study self-harm. These instruments have taken several forms including: (a)
single-item, open-ended, or dichotomous variables; and (b) structured or semi-structured
interviews designed for other purposes.
Studies utilizing open-ended, single item measures of self-harm (e.g., Boudewyn
& Liem, 1995; Martin & Waite, 1994; Sabo, Gunderson, Najavits, Chauncey, & Kisiel,
1995; Zweig-Frank et al., 1994a, 1994b) have resulted in findings with questionable
reliability, construct validity, and generalizability across studies or populations (Gratz,
31
2001). Studies utilizing dichotomous self-harm variables (e.g., Baral et al., 1998;
Schaffer et al., 1982; Zweig-Frank et al., 1994a, 1994b) assess the presence or absence of
self-harm, but do not take into account the frequency of the behavior. Gratz suggests that
clinically significant differences likely exist between individuals who repeatedly and
habitually self-harm versus those who engage in the behavior intermittently or
infrequently. Open-ended single-item and dichotomous-item instruments typically have
little or no documented reliability, but are considered valid in their ability to discriminate
between respondents who have and have not engaged in deliberate self-harm.
Studies utilizing structured or semi-structured clinical interviews originally
designed for other purposes (e.g., Demitrack, Putnam, Brewerton, Brandt, & Gold, 1990;
Haw, Hawton, Houston, & Townsend, 2003; Ross, Miller, Reagor, Bjomson, Fraser, &
Anderson, 1990; Simeon et al., 1992) provide more clinically relevant information, but
“their validity still rests on the specificity and validity of the initial question, as a
nonaffirmative response to this question will preclude any follow-up” (Gratz, 2001, p.
255). In addition, responses are not typically quantified and thus evidence of their
psychometric properties is not available. Diagnostic interviews for borderline personality
disorder typically incorporate assessment of self-harm behavior as criteria for diagnosis
(Sansone et al., 1998). For example, the Structured Clinical Interview for DSM-III-R
Personality Disorders (SCID-II; Spitzer, Williams, Gibbon, & First, 1990) includes two
self-harm items; the Diagnostic Interview for Borderlines (DIB; Kolb & Gunderson,
1980) includes one item; and the Borderline Personality scale of the Personality
Diagnostic Questionnaire-Revised (PDQ-R; Hyler & Rieder, 1987) includes three self-
harm items.
32
More recently, instruments designed for the specific purpose of assessing
deliberate self-harm have been developed (e.g., Gratz, 2001; Ousch et al., 1999; Zlotnich
et al., 1996). The ability to quantitatively measure self-harm has been one of the newest
advances in the field and allows for a more discriminating analysis of the phenomena.
These newer instruments are typically comprised of multiple Likert-scale items with
several indicators of test reliability and construct validity.
Numerous researchers in the field (Gratz, 2001; Klonsky et al., 2003; Paul et al.,
2002) have identified the need for standardized and validated measures of self-harm to
further the field. Klonsky et al. suggest that the “most important next step for future
research on self-harm is the development of a detailed clinical interview to assess the
presence, phenomenology, and functions of deliberate self-harm” (p. 1507).
Summary
The multifaceted nature of deliberate self-harm provides numerous avenues for
psychological investigation. This has resulted in findings regarding phenomenology,
etiology, clinical correlates, and intrapsychic motivational factors. However, while the
clinical significance of deliberate self-harm has prompted a proliferation of clinical
research the methodological basis upon which much of this research has been conducted
is questionable. This has resulted in a fragmented and inconsistent literature base replete
with uncertain and contradictory findings. The most apparent flaw is the lack of
consistency with which deliberate self-harm has been defined and measured. Given that
science rests upon the adequacy of its measurement, improving the standards for
measurement of self-harm will improve the quality of the instruments psychologists
employ (Foster & Cone, 1995). Currently, no studies have been conducted to examine the
33
state of instrument development in the field of deliberate self-harm. Thus, it appeared
prudent to review and critique those instruments with which the majority of the research
has been conducted. The following chapter outlines the method of instrument review, the
role of psychological assessment in clinical research, and the fundamental principles used
in psychometric evaluation to provide a context within which the evaluation of
instruments was conducted.
34
CHAPTER III
PLAN OF ACTION
This chapter presents the plan of action for this review, the following sections of
this chapter include: (a) an overview of psychological assessment, (b) an overview of
psychometric evaluation, (c) strategies for identifying self-harm measures, and (d) the
plan for evaluating self-harm measures.
Psychological Assessment
Defined in its most simple terms psychological assessment refers to the
systematic measurement of a person's behavior (Haynes et al., 1995). Psychological
assessment as a process of information collection incorporates identified targets of
measurement, measurement strategies, and the inferences and clinical judgments derived
from the obtained measures. Five general reasons for conducting psychological
assessment have been identified including the need to describe or categorize behavior; to
understand more about a phenomenon; to predict behavior; to control, intervene with, or
change behavior; and to evaluate change over time (Foster & Cone, 1995). Reflecting the
variability of topics of interest, psychological assessment includes different assessment
paradigms (e.g., personality versus behavioral), assessment methods (e.g., direct
observation versus self-report), and assessment instruments.
An assessment instrument refers to the particular method of collecting data, as
well as, all the elements of the measurement process that can affect the data obtained
(e.g., instructions, individual items, response formats, coding systems, and situational
factors of administration). The complexity of developing and validating psychological
35
assessment instruments is often a limiting factor in the advancement of the field. The
importance of valid and reliable psychological assessment is paramount, as it affects a
broad range of clinical judgments including (a) the development of causal models, (b) the
design of intervention programs, (c) the prediction of future behavior, and (d) the
evaluation of treatment effects (Haynes et al., 1995). Two general classes of instruments
exist, behavioral and construct-based instruments.
Haynes et al. (1995) make the assertion that most targets of measurement in
psychological assessment are constructs “in that they are theoretically defined attributes
or dimensions of people” (p. 239). They further noted that these constructs vary in their
level of specificity; ranging from latent variable constructs to manifest variables.
However, Foster and Cone (1995) argue that inferences must be drawn regardless of the
target of measurement, as operational definitions of even the most overt behavior are
debatable.
Behavioral-based assessment instruments are designed to assess individual actions
that are either observable by others (e.g., overt behavior) or by the self (e.g., covert
behavior). Since the assessor’s interest is in describing item responses and not in drawing
inferences about underlying constructs, the phenomenon of interest should be completely
operationalized by the measurement instrument (Foster & Cone, 1995). In essence,
results from behavioral-based assessment instruments describe what people do (Goldfried
& Kent, 1972). In contrast, construct assessment instruments are designed to measure
unobservable concepts, attributes, or variables. Constructs are hypothetical entities used
to describe psychological principles and operations (Foster & Cone). Thus, although
construct-based assessments describe characteristics people have (Goldfried & Kent), the
36
results only serve as indicators of the underlying construct. Moreover, because constructs
are considered more than their behavioral signs, assumptions must be made regarding
what scores represent (Foster & Cone).
Foster and Cone (1995) note that distinguishing between measures of constructs
and behavior is difficult for several reasons. First, both measures entail gathering
information on a series of specific items or responses that may or may not be inherently
related. Second, the interpretation of the assessor is as important as the measure itself.
Test developers and assessors alike often fail to state explicitly whether they believe a
hypothetical construct or a class of behavior is being assessed. Third, common labels
such as “behavioral assessments” are not always synonymous with observational
strategies, nor are “construct-measures” synonymous with self-report or standardized
tests. However, Foster and Cone suggest that in terms conducting an appropriate
psychometric evaluation, distinguishing between behavioral and construct instruments is
conceptually important. This review contains instruments designed to assess both overt
behavioral aspects of self-harm (i.e., method, frequency, duration) and covert
psychological aspects of self-harm (i.e., motivation, function, intent). Therefore, for the
remainder of this review the term “variable” will be used to refer to general targets of
measurement. When differences between behavior-based assessment instruments and
construct-based assessment instruments need to be articulated the appropriate terms (i.e.,
behavior/al and construct) will be utilized.
Psychometric Evaluation
Assessment instruments are rarely able to provide absolute truth about the
variables they measure. Instead, the assessment results represent the measurement of
37
variables of interest (Myers & Winters, 2002). Given that measurement is a systematic,
though imprecise process of assigning a number or value to a variable, it is subject to
error, and thus variability in its functioning (Myers & Winters). The examination and
estimation o f measurement error is accomplished by evaluating the psychometric
properties o f an instrument. Assessment of an instrument’s psychometric properties
reveals how relevant the measure and its resulting scores are for selected applications.
Myer and Winters point out several deficiencies in the psychometric evaluation of
measures. First, rarely are all psychometric properties of an instrument reported. Second,
the quality of psychometric data will often vary depending upon the methods of
assessment utilized. Third, the psychometric data available will often vary in its
applicability to the needs of the evaluator. Evaluators may intend to utilize a measure for
specific purposes that require specific psychometric properties more than others.
Understanding psychometric evaluations and the data they provide is an important aspect
in developing, selecting, and administering assessment instruments. The following is a
brief review o f the psychometric properties assessed within this review.
Reliability
The reliability of an instrument refers to its degree of stability or consistency
(Groth-Mamat, 1999). It reveals the consistency with which the instrument performs the
same way across persons, situations, and time. Underlying the concept of reliability are
several sources of error including natural variation in performance, difficulty
operationalizing behavior, and the inherent imprecision of indirectly measuring
psychological constructs. Three general approaches to reliability are reviewed: (a)
38
internal consistency (item-to-item), (b) test-retest reliability (time-to-time), and (c)
interrater reliability (rater-to-rater).
Internal Consistency
Estimates of internal consistency refer to the degree to which all items within an
instrument correlate with each other (Myers & Winters, 2002; Vogt, 1999). Internal
consistency is typically estimated using Cronbach’s coefficient alpha or split-half
reliability. Cronbach’s Alpha is the most common measure of internal consistency and
provides an estimate of the average correlation among items. Split-half reliability
indicates how well half o f the items correlate with the other half. For either of these
estimates of internal consistency, coefficients exceeding 0.70 suggest that the items in an
index are measuring the same construct (Vogt).
Test-Retest Reliability
Test-retest reliability, or stability, refers to the degree to which an instrument
produces consistent results across time. The interval between assessment administrations
and the relative stability of the variable(s) being measured are significant factors in
interpreting test-retest reliability coefficients. In general, after 1 to 2 weeks correlations
greater than .80 are suggestive of adequate stability. For intervals over one month in
duration correlations greater than 0.70 are considered reasonably stabile (Myers &
Winters, 2002).
Interrater Reliability
Interrater reliability refers to the concordance between different raters of the
instrument. It is most applicable to clinician-rated instruments where scoring is based
partially on clinical judgment (Myers & Winters, 2002). Groth-Mamat (1999) advise that
39
instruments that require even partial subjectivity in scoring should be assessed for
interrater reliability. Coefficients greater than 0.80 are considered acceptable.
As previously mentioned the most appropriate indicator of reliability is dependent
upon the nature of the variable being assessed and the intended purpose of the assessment
(Groth-Mamat, 1999). For instance, estimates of internal consistency are more
appropriate when the variable is subject to frequent fluctuations or the intended purpose
is an accurate one-time assessment. Conversely, test-retest reliability is more appropriate
when the variable is relatively stable or the intended use is to examine change over time.
Generally, higher estimates of reliability bolster confidence in inferences made from test
data; however, lower estimates of reliability are less concerning if some basis exists for
believing an instrument provides valid data regarding the variable of interest (Groth-
Mamat).
Validity
The validity of an instrument is the most crucial aspect of psychometric
evaluation. “Whereas reliability addresses issues of accuracy and consistency, validity
assesses what the test is to be accurate about” (Groth-Mamat, 1999, p. 17). Thus, validity
assessment involves evaluating the meaning and inferences drawn from measurement
data and not the instrument itself (Foster & Cone, 1995). Numerous methods exist for
evaluating the validity of an assessment instrument. However, for the basis of this review
the following general categories of validity will be elaborated: (a) whether the elements
o f an instrument elicit construct-relevant responses/data (content validity); (b) whether
assessment responses/data relate to other measured outcomes, either concurrently or in
the future (criterion-related validity); (c) whether assessment instruments are
40
unidimensional or multidimensional (factorial validity); and (d) whether assessment
responses/data are consistent with theoretical concepts (construct validity).
Content Validity
Content validity refers to the “degree to which elements of an assessment
instrument are relevant to and representative of the targeted construct for a particular
assessment purpose” (Haynes et al., 1995, p. 238). Thus, when evaluating the content
validity of an instrument the focus is upon the underlying theoretical framework and the
operationalization of the construct of interest. Content validity has serious implications
for the inferences that can be drawn from assessment data including diagnosis, the
prediction of behavior, causal and functional relationships, and estimates of treatment
effects (Haynes et al.). These inferences would be compromised to the degree that the
instrument elements were inappropriate for the targeted construct and assessment
purpose.
The foundation of an instrument’s content validity is a precise, detailed, and
theoretically derived conceptualization and operationalization of the target construct. In
order to assess the validity of this foundation, a familiarity with the relevant literature is
critical. A thorough review of the literature assists in clarifying the nature and boundaries
of the construct, identifying existing problems with assessment, and assessing the
operationalization of the construct (Clark & Watson, 1995; Haynes et al., 1995). The
content validity of an instrument is difficult to assess for several reasons. First, because
the content validity of an instrument varies depending upon how “precisely the construct
is defined and the degree to which "experts" agree about the domain and facets of the
construct,” establishing the content validity of an instrument designed to assess constructs
41
with uncertain definitional boundaries or inconsistent definitions is difficult (Haynes et
al., p. 239). As our conceptualization of a construct changes, the relevance and
representativeness of an instrument’s elements degrade, thus affecting the content
validity of the instrument. Therefore, the content validation unavoidably involves
continual refinement of all aspects of an assessment instrument including, but not limited
to its operational definition, item content, presentation of stimuli, instructions, behavior
codes, time-sampling parameters, and scoring systems (Haynes et al.; Smith &
McCarthy, 1995). As such, assessing content validity is a multi-method process that
includes both quantitative and qualitative processes.
All quantitative indices of validity are relevant to the content validity of an
instrument (Haynes et al., 1995). However, properly evaluating the content validity of an
instrument involves several qualitative evaluations of its conceptualization and
development. The following questions and their relevant content are important: (a) is the
construct of interest properly and comprehensively defined as consistent with the
theoretical literature; (b) are the intended functions of the instrument specified; (c) how
was the initial item pool generated (i.e., expert sampling, literature review, clinical
experience); (d) does the instrument include items designed to reflect the relative
importance of the various facets of the target construct; and (e) were all elements of the
instrument quantitatively evaluated by experts and potential respondents.
Criterion-Related Validity
The assessment of criterion-related validity involves comparing instrument scores
to some criterion of practical value and is more empirically based than content validity
(Haynes et al., 1995). Establishing the criterion-related validity o f an instrument provides
42
an elaboration of the instrument results and provides greater confidence that the
instrument is measuring the target variable (Myers & Winters, 2002). Criterion selection
is an inherently inexact and difficult aspect of criterion-related validity as it depends upon
the intended purpose of the instrument, as well as the theoretical assumptions underlying
the particular construct (Groth-Mamat, 1999; Haynes et al.). Foster and Cone (1995) note
that appropriate criterion instruments are best selected during the development of the
instrument as “explicit tests of differential predictions about the expected patterns of
relationship that would support convergent and discriminant validity are more impressive
than post hoc interpretations of large matrices of contradictory correlations” (p. 1046).
Criterion-related validity can be generally divided into either predictive or
concurrent validity. The main consideration in deciding whether one is more appropriate
depends upon the intended purpose of the instrument (Groth-Mamat, 1999). Evaluating
concurrent validity is more relevant to instruments designed to assess a respondents
status, whereas predictive validity is more relevant to instruments designed to correlate
with some event that will occur in the future. For the purpose of this review predictive
validity will not be explicitly review. However, the procedures for establishing predictive
validity closely resemble that of establishing concurrent validity. Establishing the
concurrent validity of an instrument entails correlating it with another simultaneously
administered instrument that is believed to be valid. Concurrent validity can be further
divided into convergent and discriminant validity (Myers & Winters, 2002).
Convergent validity refers to the overlap between different tests that presumably
measure the same construct (Vogt, 1999). Establishing the convergent validity of
construct-based instruments is especially important as the use of the instrument is
43
predicated upon the assumption that it measures a particular construct of interest. Foster
and Cone (1995) suggest that when interpreting the correlation coefficients of convergent
instruments several factors should be considered. First, are the comparison instruments
sufficiently different as to reduce shared method variance? Second, how reliable and
valid are the results of the comparison instruments? Third, does the comparison
instrument assess the same or similar construct? Finally, does the comparison instrument
operationalize the construct in the same or similar manner?
Establishing the discriminant validity of an instrument is another important aspect
of the validity process and involves showing that an instrument does not relate to other
unrelated theoretical constructs (Foster & Cone, 1995). Thus, the discriminant validity of
construct-based instruments speaks to the degree to which the instrument content assesses
a distinct construct (Foster & Cone). In contrast, with behaviorally based measures,
establishing the discriminant validity of an instrument is more heavily dependent upon
established quantitative results indicating that two behavioral variables are unrelated
(Foster & Cone).
Factorial Validity
The factorial validity of an instrument refers to the psychometric stability of its
underlying factor structure. Factor structure refers to whether an instrument is composed
of separable dimensions; each representing a theoretical construct (Myers & Winters,
2002). Multifactorial instruments include separate factors as specific manifestations of a
more general construct and serve as subscales for the instrument (Clark & Watson, 1995).
If each factor can be measured reliably and validly, then their identification “can add
44
substantially both to understanding the research domain and to interpreting scores on the
measure” (Clark & Watson, p. 1043).
Exploratory and confirmatory factor analyses are two common statistical
procedures used to evaluate the factor structure of an instrument. Exploratory factor
analysis is used to discover what latent factors underlie a set of variables or measures and
is often used during the developmental phase of data reduction and item selection. This is
often contrasted with confirmatory factor analysis, which is considered more theoretically
advanced, and tests preconceived hypotheses about underlying factors (Vogt, 1999).
Confirmatory factor analysis is one method of assessing construct validity as the
hypothesized factor structure that the instrument is purported to measure is derived from
a theoretical understanding of the domain of interest (Clark & Watson).
Regardless of type, factor analytic procedures determine if several highly
correlated items (inter-item correlations) constitute a common underlying dimension or
factor. However, inter-item correlations should be systematically higher than the
correlations between items from different factors (Clark & Watson, 1995). For
multifactorial instruments, the average inter-item correlation is a much more appropriate
index of internal consistency than coefficient alpha. Clark and Watson recommend that
the average inter-item correlation fall in the range of .15 - .50. Moreover, while factors
are expected to be distinct from each other they are also expected to evidence a strong
relationship with the overall instrument score (total-item correlations); (Bordens & Abbot
1996). The results of factor analytic techniques can also be used to evaluate the internal
consistency, as well as the discriminant and convergent validity (Floyd & Widaman,
1995).
45
Construct Validity
References to the construct validity of an instrument do not necessarily denote a
concrete statistical property, but rather an overarching concept that subsumes all other
categories o f validity (Haynes et al., 1995). In its most basic form, construct validity
refers to the degree to which an instrument measures the construct o f interest. Foster and
Cone (1995) suggest that at least 3 components are necessary to evaluate the construct
validity of an instrument including: (a) an articulated theory of the construct, (b)
hypothesized relationships between constructs and their observed manifestations, and (c)
empirical data regarding these hypothesized relationships. These suggestions imply that
without an articulated theory there can essentially be no construct validity.
Varieties of approaches exist to evaluate the construct validity of an instrument
and that each can yield discordant results (Haynes et al., 1995). The most common
sources of evidence for the construct validity of an instrument are the reliability, content
validity, criterion-related validity, and the factorial structure of an instrument. Thus, for
an instrument to be considered construct valid it must reliably measure all facets of the
construct of interest, adequately represent the content of interest, and converge and
diverge with other constructs in a theoretically consistent manner.
The construct validity of an instrument is directly related to its clinical utility, as
clinical inferences are only as valid as the data upon which they were drawn (Clark &
Watson, 1995; Haynes et al., 1995). Thus, properly evaluating the construct validity of
assessment instruments is crucial in developing the most precise and efficient measures
possible (Haynes et al.). The greater the amount of supporting data generated, the greater
confidence one can have in the instrument being used. Theoretical conceptualizations
46
change over time necessitating continual evaluation of construct validity (Groth-Mamat,
1999).
Strategies for Identifying Self-Harm Measures
A comprehensive review of the literature was conducted to identify instruments
for inclusion in this review. Several methods were used. The following computerized
databases were searched: Social Sciences Abstracts, Medline, PsycINFO,
PsychARTICLES, Mental Measurements, and Dissertation Abstracts. Numerous search
terms were used to identify instruments relevant to measuring deliberate self-harm. The
terms “deliberate self-harm,” “self-harm,” “self-mutilation,” “self-injury,” “self-injurious
behavior,” “self-destructive behavior,” “self-inflicted wounds,” and “parasuicide” were
entered into keyword, default, and title keyword searches. The resulting articles were
reviewed in regards to the use of an identifiable measure of self-harm. Additional
information regarding the use of self-harm measures in published journal research was
obtained via a search of the internet utilizing the Google Advanced Search facility
(www.google.com/advanced_search). Additionally, several prolific researchers who had
published articles in which self-harm was measured were contacted to identify additional
instruments and to obtain further information on the psychometric characteristics of their
measures.
Criteria for Inclusion
Two classes of instruments were reviewed including instruments in which self
harm is the primary or exclusive construct measured, as well as instruments in which self
harm is reported as a component of the instrument. The identification of instruments
including small numbers of items relevant to deliberate self-harm is beyond the scope of
47
this review. In addition, the content of these measures rarely includes more than simple
screens for the presence or absence of deliberate self-harm behavior.
Given the lack of empirically validated and standardized measures of self-harm,
instruments were included within this review if they had been utilized in published
articles or book chapters. In cases where the measure had been utilized in a published
work but the psychometric data were not reported, the instruments and relevant
psychometric data were obtained directly from the author of the instrument and/or the
author of the study. However, limited use of unpublished psychometric data was included
and all efforts were made to substantiate claims regarding validity and reliability.
Criteria for Exclusion
Two classes of instruments were not included within this review. First,
instruments designed to assess variables related to self-harm (i.e., Borderline Personality
Disorder, Eating Disorders, etc.), but do not themselves collect sufficient data to measure
self-harm are not reviewed. For instance, numerous scales designed to diagnose
borderline personality disorder (e.g., DIB; Kolb & Gunderson, 1980; PDQ-R; Hyler &
Rieder, 1987) include limited items to assess the presence of absence of deliberate self-
harm. These scales while inclusive of deliberate self-harm do not provide sufficient
information to provide a quantifiable measurement. Second, numerous single-use
measures have been developed for both published research and unpublished doctoral
dissertations. These instruments are rarely described and typically include rudimentary
assessment of presence, frequency, and method of self-harm. These instruments were not
reviewed unless they had been utilized in other studies and descriptions, psychometric
data, and operational definitions were available.
48
Categorization o f Review
The instruments included within this review can be grouped into the following
categories (a) detection, and (b) intent and lethality assessment. Narrow-band (i.e.,
instruments focused specifically on deliberate self-harm) and broadband instruments (i.e.,
instruments focusing on a wider range of self-destructive behaviors, but including
questions about deliberate self-harm) are reviewed. Both self-report and clinician
administered assessments, as well as behavioral and construct-based instruments are
reviewed.
Plan for Evaluating Self-Harm Measures
Each instrument is reviewed individually according to the following criteria.
Information is provided for each instrument regarding its general features including:
amount of items, response format, types of information collected, scoring systems, and
the length of time needed to complete. In addition, each instrument is described regarding
its operational definition of self-harm, development/samples studied, dimensionality,
reliability, and validity. Each criterion for evaluation is further elaborated upon below.
Operational Definition
Findings from studies of self-harm behavior are often difficult to integrate or
interpret because of the differing definitions of self-harm behaviors that are used;
differing definitions can yield markedly different research results. Therefore, the
instruments in this review are evaluated with regard to how self-harm behavior is
operationalized and how closely these definitions correspond to that proposed by Gratz
(2001). This definition was proposed as a direct result of the problems in communication
49
engendered by the inconsistent manner in which terms and definitions have been used by
researchers and clinicians working within the field of self-harm.
In an attempt to establish a common nomenclature and improve communication,
Gratz (2001) proposed that the term “Deliberate Self-Harm (DSH)” be used when
referring to a broader category of behavior including cutting, burning, and scraping.
Deliberate self-harm is defined as “the deliberate, direct destruction or alteration of body
tissue without conscious suicidal intent, but resulting in injury enough for tissue damage
(e.g., scarring) to occur” (Gratz, p. 254). Culturally sanctioned self-harm and drug
overdoses are excluded from this definition. Based on this definition and several
suggested dimensions of self-harm assessment (Pattison & Kahan, 1983; Walsh & Rosen,
1988) three pertinent questions must be asked when evaluating self-harm instruments:
First, is it implicit or explicit in the instrument directions/ items that the behaviors
of interest are associated with zero intent to kill oneself? Self-harm instruments should
not be worded so broadly as to elicit information about self-damaging behaviors that are
associated with suicidal intent.
Second, is it implicit or explicit in the instrument directions/items that the
behaviors of interest are associated with socially unacceptable behaviors? Self-harm
instruments should be worded in such a manner as to exclude socially acceptable forms
of bodily harm (i.e., tattoos, scarification, ear piercing, etc.) intended to beautify the
body.
Third, is it implicit or explicit in the instrument directions/items that the behaviors
of interest are associated with direct forms of self-harm that result in visible tissue
damage? Self-harm instruments should not be worded in such a manner as to potentially
50
elicit information regarding indirect forms of self-harm (e.g., eating disorders, drug use,
unprotected sexual behavior, etc.), as these behaviors, while dangerous are not direct
methods o f damaging body tissue (Favazza, 1998; Pattison & Kahan, 1983).
The use of common definitions for describing deliberate self-harm does not
ensure that respondents will always respond in the manner intended, but it does ensure a
degree o f consistency in approach, therein enhancing communication among researchers
and clinicians (Goldston, 2000). Therefore, the term deliberate self-harm will be used for
the purposes of this review. The exception to this use of terminology is when the body of
another author’s work is cited within this review, in which case, their terminology will be
used.
Development/Samples Studied
Because the prevalence of deliberate self-harm varies among different
populations, instruments that may have utility in identifying and describing individuals in
one population may not be as useful in another population. Therefore, the primary
samples use to establish the psychometric properties of each instrument are described.
Moreover, when available, information with respect to differences in scale properties
among samples is presented.
Dimensionality
The factor structure of instruments that have been subjected to factor analysis are
reported along with particulars regarding their analysis, psychometric properties, scale
composition, and content.
51
Reliability
All instruments included in this review are described and evaluated with regard to
their internal consistency. Depending upon the nature of the scale and the availability of
data, test-retest and interrater reliability are also evaluated.
Validity
The construct validity of an instrument is affected by all aspects of its
development, implementation, and interpretation. As such, construct validity subsumes
all other categories of validity and is assessed in various manners depending upon the
nature o f the instrument, data collected, and the purposes of the assessment (Messick,
1993). Contingent upon the availability o f data, instruments are reviewed in terms of their
convergent validity, discriminant validity, predictive validity, and factor structure.
Summary
This study reviewed and critiqued the most relevant and widely used instruments
of deliberate self-harm. It provides clinicians and researchers alike important information
regarding the strengths, weakness, and psychometric properties of commonly used scales.
This information can be used to evaluate existing findings, clarify methodological
inconsistencies, and develop future instruments. As such this study is but a first step in
addressing the often neglected topic of deliberate self-harm measurement.
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CHAPTER IV
INSTRUMENT REVIEW
The following review provides clinicians and researchers with a general overview
of each instruments format, psychometric properties, strengths, and weaknesses. The
instruments reviewed are divided into the following categories: (a) detection instruments,
and (b) severity assessment instruments. Each section is limited in its comprehensiveness
as several measures were unavailable for review. Each measure was reviewed in a
systematic format modeled after several similar reviews of suicide assessment
instruments (Brown, 2000; Goldston, 2000; Range & Knott, 1997; Winters, Myers, &
Proud, 2002). Data for each measure is presented in a uniform structure including the
following sections: (a) description, (b) operational definition, (c) development/sample
studies, (d) dimensionality, (e) reliability, (f) validity, (g) summary, and (h) reference.
The lack of data relevant to any of the aforementioned content areas was noted briefly
within the section and addressed within the summary and evaluation section for that
instrument.
Detection Instruments
This section of the review focuses on instruments/questions developed for
detecting either the presence or absence of current and/or past self-harm behavior (if self-
harm behaviors are conceptualized as discrete entities) or the degree of self-harm (if self-
harm behaviors are conceptualized as being along a continuum). These instruments are
often used in studies describing the phenomenology of self-harm. Both self-report and
clinician-administered instruments are reviewed.
53
Self-Report Detection Instruments
Reviewed in this section are self-report instruments for assessing deliberate self-
harm behavior. These instruments typically consist of a set of items preceded by
instructions designed to explain the purpose of the instrument and to provide guidelines
regarding behaviors of interest. Self-report formats are applicable to respondents who are
literate, cognitively capable, and relatively insightful.
Deliberate Self-Harm Inventory (DSHI)
Description. The DSHI (Gratz, 2001) is a 17-item self-report measure of
deliberate self-harm. The inventory is considered to be behaviorally based as it inquires
about sixteen specific self-harming behaviors including: (a) cutting, (b) burning with
cigarette, (c) burning with lighter or match, (d) carving of words into skin, (e) carving of
pictures or designs into skin, (f) scratching, (g) biting, (h) rubbing with sandpaper, (i)
dripping acid on skin, (j) scrubbing skin with household cleaners, (k) sticking with sharp
objects, (1) rubbing with glass, (m) breaking bones, (n) banging one’s head, (o) punching
self, (p) picking wounds, and (q) other. For each type of self-harm the DSHI assesses the
age at initiation, frequency, length of time since last episode of self-harm, duration, and
resulting hospitalization or medical attention. The measure yields a total frequency of
self-harm score, which is derived by summing the frequency of each self-harm behavior.
Operational definition. The DSHI is based upon a clearly defined definition of
deliberate self-harm. For the purpose of this instrument deliberate self-harm is defined as
the “deliberate, direct destruction or alteration of body tissue without conscious suicidal
intent, but resulting in injury severe enough for tissue damage to occur" (Gratz et al.,
2002, p. 131).
54
Development/samples studied. The authors report that the instrument items were
derived from clinical observations, client testimonies, and behaviors commonly reported
in the literature. The DSHI was initially administered to a sample of 150 college students
at the University of Massachusetts Boston. The initial sample was predominately female
(68%), heterosexual (97%), and single (81%). The average age was 23.19 years (SD =
7.13). The sample was 60% Caucasian, 16% Asian America, 13% African American or
another ethnic group of African descent, 5% Hispanic American, and 4% from other
racial/ethnic backgrounds (Gratz, 2001). In subsequent samples, the author administered
the DSHI to an additional 357 college students (73% female, 27% male); (Gratz &
Roemer, 2004).
Dimensionality. No published factor analytic results were located.
Reliability. The DSHI evidenced high internal consistency (a = .82). Item-total
correlations ranged from rb= .65 and rb= .63 for needle-sticking and skin-cutting to rb=
.12 and r* = .14 for bone-breaking and sand-papering. The authors noted that 13 of the
items had item-total correlations above rb= .33. Test-retest reliability was adequate after
a mean interval of 3.3 weeks (0 = .68, p < .001; n - 93). In addition, a high correlation (r
- .92, p < .001) was found between the number of self-harming behaviors endorsed on
the first and second administrations. These results suggest that the DSHI has the ability to
reliability classify participants as self-harming or not.
Validity. Convergent validity was examined by correlating frequency of self-harm
with scores on the Borderline Personality Organization Scale (Oldham et al., 1985). The
correlation was significant and in the predicted direction (r = .48, p < .001; Gratz, 2001).
Discriminant validity was evaluated by correlating the DSHI variable scores with several
55
measures thought to be unrelated with self-harm (e.g., suicide attempts, age, hours
employed, history of therapy, and social desirability). Correlations were in the predicted
direction, although suicide attempts (r = .20, p < .05), history of therapy (r = .21, p < .01),
and social desirability (r - .21 ,P < .05) were significantly correlated with the DSHI.
Summary. The DSHI is intended for research use with non-clinical, college-aged
populations. The DSHI has several strengths including: (a) a behaviorally-based format,
(b) literature derived item selection and development, and (c) published data on its
preliminary psychometric evaluation. However, several weaknesses exist which were
commented upon by Gratz (2001) in the original publication. First, the convergent
validity of the DSHI was established using unvalidated criterion measures. Second, the
external validity of the DSHI is limited given the non-clinical, college-aged nature of its
validation sample. Third, the discriminant validity of the DSHI requires additional
evaluation with respect to measures of psychopathology. Lastly, the DSHI fails to
incorporate all data collected (frequency, duration, and severity of self-harm) into a single
outcome score.
Reference. Gratz, K. L. (2001). Measurement of deliberate self-harm: Preliminary
data on the deliberate self-harm inventory. Journal of Psychopathology and Behavioral
Assessment, 23(4), 253-263.
Self-Harm Behavior Questionnaire (SHBQ)
Description. The SHBQ (Guiterrez, Osman, Barrios, & Kopper, 2001) is a 14-
item, self-report measure of suicide risk. The SHBQ was designed to assess four
theoretically distinct aspects of suicide related behaviors: (a) non-suicidal self-harm, (b)
suicide attempts, (c) suicide threats, and (d) suicide ideation. Each section contains open-
56
ended, free-response format, follow-up questions designed to elicit information regarding
the intent, lethality, and outcome of the behavior, thought, or verbalization being
reported. Most relevant to this review are the following dimensions of non-suicidal
deliberate self-harm including: (a) type of behavior, (b) frequency, (c) ages at first and
most recent incident, (d) notification of someone regarding their self-harm, and (e) the
need to see a doctor after self-harm. The SHBQ contains a detailed coding system that
allows for the quantification of both categorical and free-response variables into
numerical values weighted by seriousness of the behavior reported. The SHBQ scoring
system results in a total score, as well as 4 subscale scores.
Operational definition. Self-harm is operationally defined as “self-harm behavior
that the individual did not identify as suicidal in nature” (Gutierrez et al., 2001, p. 477).
The respondent must make a subjective decision regarding what they consider self-harm
behavior with non-lethal intent.
Development/samples studied. The SHBQ was initially administered to a sample
o f 342 college students. The sample was predominately single (98.2%) females (59%)
with an average age of 19.48 years (SD = 1.52). The sample was 95.9% Caucasian, 2.3%
Asian America, 0.6% African America, and 1.2% from other racial/ethnic backgrounds.
In subsequent samples, the SHBQ has been used to examine self-harm and suicidal
behavior in 673 undergraduate students (Gutierrez, Rodriguez, & Garcia, 2001) and high
school students ranging from 14-18 years of age (Muehlenkamp & Gutierrez, 2004;
Valentiner, Gutierrez, & Blacker, 2002).
Dimensionality. Gutierrez et al. (2001) assessed the factor structure of the SHBQ
using principle axis factor analyses with varimax and promax rotations. They identified
57
four distinct factors which accounted for 80.1% of the variance in sample data: Past
Suicide Attempts (2=1.51), Self-Harm (2=2.03), Suicide Threat (A=1.96), and Suicidal
Ideation (2=1.42) (Gutierrez et al.).
Reliability. Gutierrez et al. (2001) assessed interrater reliability by randomly
selecting and recoding 171 (50%) of the protocols from the initial sample. Using subscale
scores to compute percentage agreement interrater reliability was found to be excellent (k
= .95 to .10). Similarly, Muehlenkamp and Gutierrez (2004) found the SHBQ to have
excellent interrater reliability (k = .95). In addition, the scale factors evidence high
internal consistency as assessed by Cronbach’s alpha and corrected item-total
correlations: Past Suicide Attempts (a = .96, rlt = .79 to .97); Self-Harm (a = .95, r„ = .88
to .95); Suicide Threat (a = .94 r,t = .68 to .91); and Suicide Ideation (a = .89 rit = .65 to
.90) (Gutierrez et al.).
Validity. The convergent validity of the SHBQ was assessed by correlating the
SHBQ total and subscale scores with several existing measures of suicidal behavior (i.e.,
Adult Suicide Ideation Questionnaire [ASIQ], Reynolds, 1991; Suicide Probability Scale
[SPS], Cull & Gill, 1982; Suicidal Behavior Questionnaire-Revised [SBQ-R], Osman,
Bagge, Gutierrez, Konick, Kopper, & Barrios, 2001). The results indicate that the SHBQ
has promising convergent validity as evidence by moderate to strong correlation with
widely validated measures of suicidality. Notably, significant relationships were found
between the SHBQ self-harm subscale and the ASIQ (r = .34, p < .001), SPS (r = .35, p <
.001), and SBQ-R (r = .27, p < .001).
Summary. The SHBQ is intended for use with non-clinical, adolescent and
college-aged populations. The SHBQ has several strengths that make it an innovative
58
instrument. First, it includes scoring system that translates both categorical and free-
response variables into quantifiable values. Second, it provides the researcher with both
empirically derived scores, as well as qualitative response data, which provides a context
for data interpretation. Third, it combines multiple aspects of suicide related behavior into
one instrument. Lastly, the SHBQ shows potential for differentiating among variable
levels o f suicidality, thereby showing particular promise in examining parasuicide and
repetitive self-mutilation (Winters et al., 2002).
However, while the SHBQ appears to be a psychometrically sound and
incrementally valid measure of suicidality, several factors exist which limit it's utility as a
measure o f non-suicidal deliberate self-harm. First, subscale items used to compute the
self-harm score are not comprehensive of the dimensions of self-harm assessment (i.e.,
type, analgesia, amnesia, dissociation). Second, the phrase “have you ever need to see a
doctor after doing these things” is vague in terms of identifying level of severity or
physical damage. Third, the instrument instructions lack a clear distinction between
deliberate self-harm with or without suicidal intent. Fourth, there has been no attempt to
establish the discriminant validity of the instrument.
Reference. Gutierrez, P. M., Osman, A., Barrios, F. X., & Kopper, B. A. (2001).
Development and initial validation of the self-harm behavior questionnaire. Journal of
Personality Assessment, 77(3), 475-490.
Self-Harm Inventory (SHI)
Description. The SHI (Sansone et al., 1998) is a 22-item, self-report questionnaire
designed to measure self-harm and predict diagnoses of borderline personality disorder.
The SHI contains 14 overt self-inflicted self-harm behaviors (e.g. cut, bum, hit, scratch,
59
pick wounds), three eating disorder behaviors (e.g., restricted food intake, laxative abuse)
and two high-lethal items (e.g., drug overdose, attempted suicide). Each item is preceded
by the statement, “Have you ever intentionally, or on purpose...?” Each item is scored on
a dichotomous (yes/no) format and each positive endorsement is in the pathological
direction. The SHI yields a total score, which reflects how many different types of self-
harm a respondent endorsed. Total scores range from 0 to 22 with scores greater than 5
suggestive o f diagnosable borderline personality disorder (Sansone et al.).
Operational definition. Sansone et al. (1998) provide neither conceptual nor
operational definitions of self-harm behavior within the context to the SHI. However the
inclusion of items such as “Attempted suicide,” Abused alcohol,” Driven recklessly,” and
Distanced self from God as punishment” suggest broader criteria for inclusion. In fact,
Sansone, Levitt, & Sansone (2003) have suggested that self-harm behavior “ranges from
various non-lethal forms of self-injury to genuine suicide attempts” (p. 1).
Development/samples studied. The authors report that SHI item pool was
generated from behaviors described within the literature and expert opinion. Initial item
selection was accomplished utilizing three separate subsamples. The first subsample
examined the prevalence of BPD among obese women being seen within a primary care
setting. These 61 women had an average age of 34.7 years (SD = 8.3) (Sansone, Sansone,
& Fine, 1995). The second subsample consisted of a study comparing the prevalence of
BPD among individual with eating disorders (n = 52), substance abuse (n = 44), and both
substance abuse and eating disorders (n = 17). This subsample was 89% female with an
average age of 30.3 years (SD = 9.8) (Sansone, Fine, & Nunn, 1994). The third and final
subsample examined the prevalence of BPD in mothers of obese versus normal-weigh
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adolescent girls. These 43 participants had an average age of 41.1 years (SD = 3.3)
(Sansone et al., 1998).
Validation of the SHI included two separate samples. The initial validation of the
SHI utilized two separate subsamples of women being seen within a primary health clinic
for routine gynecological care. The first subsample consisted of 133 women whose
average age was 33.11 years (SD = 9.60). The second subsample consisted of 152 women
with an average age was 33.97 years (SD = 9.0) who reported a history o f childhood
trauma (Sansone et al., 1995). The second validation study was conducted to examine the
usefulness of the SHI on a psychiatric inpatient population. This sample consisted of 32
(50% female) nonpsychotic adults with an average age of 36.2 years (SD = 13.33)
(Sansone et al., 1998).
Additionally, the SHI has been used with several psychiatric inpatient samples
(Sansone, Gaither, & Barclay, 2002a; 2002b; Sansone, Gaither, & Songer, 2001;
Sansone, Songer, & Gaither, 2000), voluntary college participants (Castillas, & Clark,
2002), as well as with several primary health care setting samples (Sansone, Sansone &
Morris, 1996; Sansone, Whitecar, Meier, & Murray, 2001; Sansone, Wiederman,
Sansone, & Monteith, 2000; Wiederman, Sansone, & Sansone, 1999).
Reliability. Castillas and Clark (2002) found the SHI to have high internal
consistency (a = .93, n =226).
Validity. The convergent validity of the SHI has been assessed in comparison to
numerous theoretically related measures. Scores on the SHI have been shown to be
highly correlated with the Diagnostic Interview for Borderlines (DIB; r = .76, n = 2 2 \ , p
61
< .01; Sansone et al., 1998) and the borderline personality disorder scale of the
Personality Disorders Questionnaire-R (PDQ-R; r = .57, n = 285, p < .01; Sansone et al.,
1995; r = .73, p < .01, n = 221; Sansone et al., 1998). Sansone, Whitecar, et al. (2001)
found the SHI to be correlated with somatic preoccupation as measured by the Bradford
Somatic Inventory (BSI; r = .65, p < .01, n = 18). Moreover, Castillas and Clark (2002)
found the SHI to be related to several subscales from the Schedule for Nonadaptive and
Adaptive Personality (SNAP; Clark, 1993) including self-harm (r = .61, p < .001),
antisocial personality disorder (r - .40, p < .001), borderline personality disorder (r = .55,
p < .001), and narcissistic personality disorder (r = .21, p < .01).
Preliminary evidence for the predictive validity of the SHI has been established,
using a cut-off score of five to predict a diagnosis of BPD (based on the DIB; Kolb &
Gunderson, 1980). Sansone et al., (1995) found the SHI to have a high sensitivity rate,
correctly classifying respondents as having a diagnosis of BPD 87.9% of the time (k =
.51,17 = 285). Similarly, Sansone et al., (1998) found the SHI to a relatively high
sensitivity rate of 81.5%, but a relatively low specificity rate of 60%. The overall
accuracy o f the SHI in correctly classifying respondents was 78.1% (k= .33); (Sansone et
al., 1998).
Summary. The SHI is intended for use with adults as a screening device for
deliberate self-harm in primary care settings, as well as psychiatric adult populations. Its’
utility as such has been adequately established and its convergent validity with several
theoretically related constructs make it a promising measure for studying borderline
personality disorder. However, as a measure of deliberate self-harm several concerns
exist. First, the inclusion of items not typically considered self-harm within the literature
62
makes interpretation and comparison o f SHI findings difficult. The inclusion of attempted
suicide as a self-harm behavior is directly antithetical to the current literature on self-
harm and the inclusion of items such as “Distanced self from God as punishment” are
difficult to classify as self-harm from any current theoretical perspective. Second, its
checklist format provides limited information other than method of self-injury. Third, the
test-retest and discriminant validity of the SHI have not been evaluated.
Reference. Sansone, R. A., Wiederman, M. W., & Sansone, L. A. (1998). The
self-harm inventory (SHI): Development of a scale for identifying self-destructive
behaviors and borderline personality disorder. Journal of Clinical Psychology, 54(7),
973-983.
Self-Injury Survey (SIS)
Description. The SIS (Simpson, Zlotnick, Begin, Costello, & Pearlstein, 1994) is
an 18-item, self-report questionnaire designed to assess three separate, but related types
of self-regulatory behaviors including: (a) indirect self-harm, (b) suicide, and (c) direct
self-harm. The first section of the SIS includes 18 indirect self-harm behaviors (e.g.,
binge eating, driving recklessly, having unprotected sex). The second section includes
questions pertaining to the number of suicide attempts and a free response area for
respondents to list the methods used and age at each attempt. The third section includes
13 direct self-harm behaviors (e.g., cutting oneself, burning oneself, carving words on
skin). Section three also assesses the frequency of direct self-harm over one’s lifetime
and the last 3 months, age at first episode, age at last episode, and presence of pain during
direct self-harm. In addition, the SIS includes a check list of reasons for direct self-harm,
types of past intervention, and damage effects.
63
Operational definition. For the indirect self-harm subscale of the SIS, respondents
are instructed to report only those self-harm behaviors that are “indirect bodily harm,
with the individual unaware of or disregarding the negative long-term effects of these
actions” (Zlotnick et al., 1996, p. 13). For the suicidal behavior subscale of the SIS,
respondents are asked about behaviors with intent to end one’s life. For the direct self-
harm subscale of the SIS, respondents are instructed to report on only those self-harm
behaviors that are “direct, deliberate, harm to one’s body without a conscious intent to
die” (Zlotnick et al., p. 13).
Development/samples studied. All items on the SIS were derived from common
self-mutilative acts reported in the literature (Zlotnick, Donaldson, Spirito, & Pearlstein,
1997). No published data were located regarding the development of the Self-Injury
Inventory (Simpson et al., 1994). However, the SIS has been used to examine self-harm
behavior in several diverse populations including adolescent psychiatric inpatients
(Zlotnick et al., 1997), adult psychiatric outpatients (Zlotnick et al., 1999), and adult
female psychiatric inpatients (Zlotnick et al., 1996).
Reliability. Zlotnick et al. (1999) assessed the internal consistency of the SIS and
found that the indirect self-harm subscale of the SIS had a Cronbach’s alpha coefficient
of .68 and the direct self-harm subscale had a Cronbach’s alpha coefficient of .76.
Validity. No published validity data were located.
Summary. The SIS is intended for research use with adult and adolescent
psychiatric samples. Limited information is available regarding the development,
evaluation, and current status of the SIS. The instrument itself was obtained from a
64
secondary source. However, the following summary can be made with the available
information. The SIS has particularly good content validity in that it covers multiple
dimensions of self-harm including: method, duration, analgesia, need for medical
attention, and use of alcohol and drugs. The SIS also clearly delineates between direct
and indirect methods of self-harm, as well as provides an assessment of motivation for
self-harm. Nevertheless, several areas for improvement exist. First, the SIS lacks a clearly
defined scoring system. Second, the SIS has scant psychometric data. In fact, no data was
able to be obtained regarding estimates of its test-retest reliability and its factorial,
convergent, or discriminant validity.
Reference. Simpson, E., Zlotnick, C., Begin, A., Costello, E., & Pearlstein, T.
(1994). Self-Injury Survey. Unpublished manuscript, Providence.
Functional Assessment o f Self-Mutilation (FASM)
Description. The FASM (Lloyd, Kelley, & Hope, 1997) is a 59-item self-report
measure designed to assess the methods, frequency, and functions of self-mutilation. The
FASM is comprised of two sections. The first section assesses the presence of self-harm
and several clinical characteristics relevant to each reported self-harming behavior.
Respondents are first asked to indicate if they have engaged in 11 different methods of
self-harm, with a space provided for any methods not listed. For each method, several
relevant characteristics are assessed including: frequency, suicidal intent, length of
preparation or thought, age at first episode, age at last episode, use of alcohol and/or
drugs during self-harm, and knowledge of similar peer behavior. Analgesia for self-harm
is assessed on a four-point Likert scale ranging from no pain to severe pain. In addition,
65
history of psychiatric treatment and suicide attempts are assessed with dichotomous
(yes/no) questions.
The second section assesses the function of self-harm behavior along two
dichotomous dimensions: automatic versus social contingencies and positive
reinforcement versus negative reinforcement (Nock & Prinstein, 2004a). The function of
self-harm is assessed by asking respondents to indicate how often they have engaged in
self-harm for each of 22 different reasons. Each function is rated on a four-point Likert
scale ranging from never to often, with a space provided for any reasons not listed.
Operational definition. The FASM operationally defines self-mutilation as "the
direct and deliberate destruction or alteration of body tissue without conscious suicidal
intent" (Favazza, 1999; cited in Guertin, Lloyd-Richardson, Spirito, Donaldson, &
Boergers, 2001). However, the FASM also includes questions designed to assess suicidal
intent.
Development/samples studied. All FASM items were derived from studies of self-
mutilation in both normative and psychiatric populations. This item pool was then
supplemented with items derived from focus group discussions with adolescent
psychiatric inpatients with histories of self-harm (Lloyd, 1998).
The FASM has been used to examine self-harm behavior in both normative (n =
57; Lloyd, 1998; Lloyd et al., 1997) and psychiatric adolescent samples (n = 108, Guertin
et al., 2001 ;n = 95, Nock & Prinstein, 2004a; 2004b).
Dimensionality. The factor structure of the FASM was examined by Lloyd and
colleagues (1997) using a principal components analysis. This analysis yielded two
factors based on severity of self-harm. The first factor was comprised of items that are
66
generally more severe (i.e., cutting/carving, burning, self-tattooing, scraping). The second
factor included items considered moderate in severity (i.e., hitting self, pulling hair,
biting self).
Nock and Prinstein (2004a) examined the factor structure of the function subscale
o f the FASM. Confirmatory factor analysis supported a four-factor structure (IFI= .91,
CFI= .90, RMSEA = .05 (C/90%= .03 to .07), X2/df= 1.41). The four subscales include:
automatic negative reinforcement (ANR; 2 items, “To stop bad feelings”), automatic
positive reinforcement (APR, 3 items, “To feel something, even if it was pain”), social
negative reinforcement (SNR, 4 items, “To avoid doing something unpleasant you don’t
want to do”), and social positive reinforcement (SPR, 12 items, “To get other people to
act differently or change”); (Nock & Prinstein).
Reliability. The FASM has been used in several published studies (Guertin et al.,
2001; Nock & Prinstein, 2004a; 2004b), which have yielded support for its psychometric
properties. Guertin et al. reported adequate levels of internal consistency for both self-
harm behavior subscales (i.e., moderate and severe forms of self-harm; r = .65 and .66,
respectively). In addition, Nock and Prinstein (2004a) reported high internal consistency
for the four function subscales (i.e., Automatic-negative reinforcement, a = .62;
Automatic-positive reinforcement, a = .69; Social-negative reinforcement, a - .76;
Social-positive negative reinforcement, a = .85).
Validity. Support for the concurrent validity of the FASM has been reported, as
evidenced by significant associations between the presence of self-mutilation and
measures of suicidal ideation, past suicide attempts (Lloyd et al., 1997; Guertin et al.,
67
2001), loneliness, risk-taking, and reckless behavior (p < .005, respectively; Guertin et
al.).
Additionally, Nock and Prinstein (2004b) found significant associations between
the FASM subscales of ANR, APR, SNR, and SNP and measures of hopelessness
(Hopelessness Scale for Children [HSC], Kazdin, Rodgers, & Colbus, 1986), loneliness
(Revised UCLA Loneliness Scale [UCLA-LS], Russell, Peplau, & Cutrona, 1980), social
perfectionism ( Child and Adolescent Perfectionism Scale, Hewitt & Flett, 1991), as well
as history of suicide attempts, PTSD, and major depressive disorder (Diagnostic
Interview Schedule for Children [DISC], Shaffer, Fisher, Dulcan, & Davies, 1996).
Summary. The FASM is intended for use research use with psychiatric and non
psychiatric populations adolescents. Several areas for improvement were identified. First,
while the reliability and structural validity of the functions factor is rather well
established, the psychometric properties of the remaining items are unevaluated. Second,
the FASM lacks test-retest and inter-rater reliability estimates. Third, the concurrent
validity of the FASM is poor as it has been established utilizing the presence/absence of
self harm rather than a continuous measure of self-harm. Fourth, failure to use alternative
measures of self-harm to establish convergent validity. Fifth, the use of a single-item
assessment of severity (e.g., Have you gotten medical treatment?) is inadequate to fully
assess this domain and is vague in its intent. Sixth, no distinction is made between
participants who self-harm with or without suicidal intent.
Reference. Lloyd, E. E., Kelly, M. L., & Hope, T. (1997). Self-mutilation in a
community sample of adolescents: Descriptive characteristics and provisional prevalence
68
rates. Paper presented at the Annual Meeting of the Society for Behavioral Medicine,
New Orleans.
Self-Injury Questionnaire (SIQ)
General description. The SIQ (Vanderlinden & Vandereycken, 1997) is a 54-
item, self-report questionnaire designed to assess several aspects of self-injurious
behavior. The VIQ can be conceptually divided into three distinct sections. First, utilizing
a 4-point Likert scale ranging from never to very often, respondents rate the likelihood of
specific behaviors occurring when the respondent is under stress or tension within the
past 6 months. Second, utilizing a 4-point Likert scale ranging from never to very often
respondents rate the likelihood of specific urges or inclinations toward self-injury within
the past 6 months. Finally, utilizing a forced-choice response format, the VIQ assesses
the presence of five specific types of deliberately self-injurious behavior (i.e., hair
pulling, scratching, bruising, cutting, and burning) within the past year. For each type of
self-injurious behavior the frequency, presence of pain, and precipitating emotions (i.e.,
nervous, bored, angry, sad, scared, other) are assessed. Additionally, three general
questions including duration of self-injurious behavior, age at initiation, most frequently
injured part of the body, and planning/spontaneity of the act are assessed. No information
is available regarding any relevant scoring system.
Operational definition. The authors utilize the term self-injurious behavior (SIB)
and define it as “a direct, socially unacceptable, repetitive behavior that causes minor to
moderate physical injury; when injuring, the individual is in a psychologically disturbed
state but is not attempting suicide nor responding to a need for self-stimulation or a
69
stereotype behavior characteristic of mental retardation or autism” (Claes, Vandereycken,
& Vertommen, 2003, p. 380).
Development/samples studied. No data are available regarding the initial
development, psychometric evaluation, or refinement of the SIQ. However, the SIQ has
been utilized with adult psychiatric inpatient (Vanderlinden, & Vandereycken, 1997) and
eating disordered populations (Claes, Vandereycken, & Vertommen, 2001; Claes et al.,
2003).
Reliability. No published reliability estimates were located.
Validity. To date no psychometric data relevant to the construct validity o f the
SIQ have been published. The lack of a scoring system for the SIQ limits methods of
construct validation. However, several studies have found that respondents identified
with the SIQ as engaging in self-injurious behavior were significantly different from non-
self-injurers on several theoretically related constructs. Vanderlinden and Vandereycken
(1997) found that psychiatric inpatients with histories of self-injury were more likely to
score in the dysfunctional range on assessments of body image, alcohol use, impulsivity,
and dissociation. Similarly, Claes and colleagues (2001, 2003) found that respondents
with concomitant self-injury and eating disorders report significantly more angry
feelings, psychiatric symptoms, borderline personality features, antisocial personality
features, and severe histories of trauma.
Summary. The SIQ is intended for use with adult psychiatric populations. While
the SIQ’s forced-choice format limits the range of behaviors assessed, it includes several
strengths of assessment including: (a) sensation of pain during each method, (b)
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emotional triggers for each method, and (c) a 4-point analgesia scale. However, the
following areas for improvement include: (a) presumption of motivation/function
(tension reduction), (b) confluence with other psychiatric disorders, (c) no explanation of
development, (d) no psychometric data, (e) the lack of a scoring system, and (f) no
delineation between suicidal and non-suicidal intent. The authors of the instrument report
that the SIQ is currently in the process of being revised and validated ; information
regarding its development, evaluation and psychometric properties is forthcoming (Claes,
personal communication, 2004).
Reference. Vanderlinden, J., & Vandereycken, W. (1997). Trauma, dissociation,
and impulse dyscontrol in eating disorders. Philadelphia: Brunner/Mazel.
Self-Harm Behavior Survey (SHBS)
Description. The SHBS (Favazza, & Conterio, 1989) is a 14-page, 178-item, self-
report instrument developed to assess several aspects relevant to self-mutilation. The
SHBS covers the following content areas including demographics, personal history,
family history, as well as a large number of behavioral, attitudinal, and emotional aspects
of self-harm such as type, frequency, age of onset, function, psychosocial consequences,
scars, suicide attempts, and treatment experiences. The SHBS inquires about 11 overt
types of self-harm (i.e., scratched or cut wrists, cut other body areas, carved words or
symbols on skin, burned skin, pulled out hair, scratched severely, broken bones, infected
self, punched face, tricked doctors into medical procedures) and includes an other
category for respondents to report unlisted methods. The SHBS includes a variety of
response formats and no established scoring system has been developed.
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Operational definition. The authors interchangeably utilize the terms self-
mutilation and self-harm to denote deliberate alteration or destruction of body tissue
without conscious suicidal intent (Favazza, & Rosenthal, 1993). Furthermore, overdoses
of drugs or alcohol regardless of intent are not included (Favazza, & Conterio, 1988).
Development/samples studied. The initial item pool for the SHBS was derived
from a review o f the literature and the author’s clinical experience (Favazza, & Conterio,
1989). A pilot version of the questionnaire was then administered to 25 habitual self-
mutilating patients to elicit feedback regarding the clarity and salience of the questions
(Favazza, & Conterio, 1988). The SHBS has been subsequently administered to several
samples including a self-selected community sample (n = 250, Favazza, & Conterio,
1988) and inpatient eating disorders populations (n = 65, Favazza et al., 1989).
Reliability. No published reliability data were located.
Validity. To date no psychometric data relevant to the construct validity of the
SHBS have been published (Favazza, personal communication, 2004). However, the
authors contend that the validity of the SHBS has been supported by the corroboration of
SHBS results with clinical information obtained from more than 100 patient medical
charts since the measure was created (Favazza, & Rosenthal, 1993).
Summary. The SHBS is a fairly comprehensive clinical interview intended for use
with both psychiatric and non-psychiatric adult populations. The SHBS is overly
comprehensive for most research purposes, but clearly has strong clinical utility as an
intake assessment for self-harm. However, a few identified areas for improvement exist
including; (a) assessment of motivation for self-harm, (b) directions which do not clearly
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delineate between suicidal and non-suicidal intent, (c) no scoring system, and (d) no
psychometric estimates of its reliability and validity.
Reference. Favazza, A. R. & Conterio, K. (1989). Female habitual self-mutilators.
Acta Psychiatrica Scandinavica, 79,283-289.
Self-Injurious Behaviors Questionnaire (SIBQ)
Description. The SIBQ (Paivio & McCulloch, 2004) is a 14-item, self-report
instrument designed to assess several dimensions of self-injurious behavior including
method/type, frequency, duration, and severity of injuries. Six specific methods of self-
injurious behavior are included in the SIBQ (i.e., cutting, burning, scratching, punching,
head banging, hair pulling). The first part of the instrument prompts respondents to rate,
on a 5-point Likert scale, the frequency with which they engaged in each of the six types
of self-injurious behaviors. A "1" indicates “never” having engaged in the behavior and
"5" indicates engaging in the behavior “very often.” The second part prompts respondents
to rate, on a 5-point Likert scale, the extent or severity of injuries typically inflicted for
each of the six self-injurious behaviors. A "1" indicates no injuries inflicted and "5"
indicates injuries severe enough to require medical attention. The final section assesses
the lifetime duration of SIB by prompting respondents to indicate the age at which they
began to self-injure and the age at which they last engaged in self-harm. The total score
on the SIBQ is the sum of the scores on these items, with higher scores indicating greater
severity and extent of engagement in SIB (Paivio & McCulloch).
Operational Definition. The authors utilized the term self-injurious behaviour
(SIB) to describe the behavior of interest. The SIBQ operationally defines SIB as the
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direct destruction of body tissue, which causes little tissue damage, and is engaged in
without the conscious intent to die (Favazza & Rosenthal, 1993).
Development/samples studied. Pavio and McCulloch (2004) note that the six
methods of self-injurious behaviors included in the SIBQ were selected based upon the
frequency with which they were cited it the literature (Briere & Gil, 1998; Favazza &
Conterio, 1988; Favazza & Rosenthal, 1993; Gratz, 2001; Osuch et al., 1999).
The SIBQ was initially administered to a sample of 100 female college students at
the University o f Windsor, Ontario Canada. The initial sample was predominately
Caucasian, single, with no children, and with a mean age of 21 years (SD = 1.66); (Paivio
& McCulloch, 2004) The SIBQ was initially developed to assess the frequency of SIB,
but has been subsequently modified to include assessment of the severity and duration of
SIB (Le & Paivio, 2002).
Le and Paivio (2002) standardized the SIBQ on a voluntary sample of 109 female
college students. The participants had an average age of 20.8 years (SD = 2.63 years) and
were predominately single (93.6 %). The ethnic/racial background of the participants was
predominantly Caucasian (85.3%, n = 93). The remaining participants were Asian (4.6%,
n = 5), Black Canadian (2.8%, n = 3), Middle Eastern (2.8%, n = 3), Aboriginal (1.8%, n
= 2), Hispanic (1.8%, n = 2), and East Indian (.9%, n= 1).
Reliability. The SIBQ showed high internal consistency (a = .84) in the initial
sample (Paivio & McCulloch, 2004). Test-retest reliability was high after a mean interval
of 3.9 weeks (0 = .78, p < .001; n = 76), suggesting that the “SIBQ is a reliable
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continuous measure of SIB on the three dimensions of frequency of behavior, severity of
injuries, and duration of behavior” (Le & Paivio, 2002, p. 15).
Validity. The convergent validity of the SIBQ was assessed by examining
correlations with a measure of alexithymia (TAS-20). Paivio and McCulloch (2004)
found the original version of the SIBQ to be significantly correlated with the TAS-20 (r =
.448,/? < .01, n = 100). Similarly, Le and Paivio (2002) found a significant correlation
between the first administrations of the SIBQ and the TAS-20 (r = .266, p < .01, n =
109).
The discriminant validity of the SIBQ was assessed by correlating it with the
SILS verbal subscale. A non-significant relationship (r = -.015, n = 109) was found
between the first administrations of the SIBQ and the SILS providing preliminary support
for the discriminant validity of the SIBQ (Le & Paivio, 2002).
Summary. The SIBQ was developed and standardized for use with non-clinical
college populations. Citing several problems with current methods of assessing self-
injurious behavior, Paivio and McCulloch (2004) developed the SIBQ to be a
standardized, reliable, and empirically validated measure of the severity o f SIB. Several
aspects of the SIBQ make it standout among other measures reviewed. First, the use of an
operational definition of SIB that is comprehensive and clinically useful enables
researchers to compare and synthesize findings across studies and populations. Second,
the ability to produce a continuous measure of lifetime extent of SIB by incorporating
frequency, severity of injuries, and duration of behavior is a clear advantage when
attempting to psychometrically evaluate the properties of the SIBQ.
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The preliminary psychometric results suggest that the SIBQ is highly reliable, and
has adequate convergent and discriminant validity. While the SIBQ is clearly an
improvement over other measures of SIB that have either poor or no psychometric data,
additional validation is needed. The authors note that future research should include
administration and validation of the SIBQ with other non-clinical populations (Le &
Paivio, 2002). However, as noted by Le and Paivio, establishing the construct validity of
the SIBQ is difficult given the general lack of other empirically validated measures of
SIB.
Reference. Paivio, S. C., & McCulloch, C. R. (2004). Alexithymia as a mediator
between childhood trauma and self-injurious behaviors. Child Abuse & Neglect, 28(3),
339-355.
Self-Injury Motivation Scale - Version 2 (SIMS-2)
Description. The SIMS-2 (Osuch et al, 1999) was developed to assess motivation
for self-injury and consists of 36 self-report items. Each item is scored on a 10 point
Likert-scale, anchored with “never” and “always,” respectively. Participants are directed
to circle the number that best corresponds to their estimation of how often the item is a
motivation for self-injurious behavior. The measure takes between seven to fifteen
minutes to complete. The SIMS-2 yields six continuous scores including: a sum total
score and 6 separate factor scores. The authors note that the use of averages in
determining total scores were contraindicated as the individual item scores were skewed
toward zero and differences were easier to appreciate with sums.
Operational definition. Self-injury was defined as socially unacceptable
“intentional physical self-harm without suicidal intent” (Ousch et al., 1999, p. 334). The
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author conceptualizes self-injury as a spectrum of behaviors spanning from socially
acceptable self-injury (i.e., intent is to beautify the body) to socially unacceptable self-
injury (i.e., intent is not to beautify, but which serves other purposes).
Development/samples studied. The authors report that the instrument items were
generated from a comprehensive review of the literature regarding the intent, motivation,
or purpose of self-harm and were designed to consider a variety of adult patient groups.
The SIMS-2 was initially administered to 99 psychiatric inpatients (44 from a
general adult unit, 55 from a trauma disorders unit). The sample was predominately
Caucasian (93%), female (79%), and averaged 38.75 years of age. Respondents were
recruited whether or not they engaged in self-injury and authors screened out respondents
with only suicidal self-injury. Additionally, the authors (Ousch et al., 1999) reference an
unpublished pilot study, which found that inpatient; chronically thought-disordered
individuals were not able to meaningfully complete the SIMS-2.
Dimensionality. The factor structure of the SIMS-2 was assessed using
confirmatory factor analysis. The authors report that "scree plots, eigenvalues, and
preliminary factor analysis supported a six-factor solution" including: Affect Modulation,
Desolation, Punitive Duality, Influencing Others, Magical Control, and Self-stimulation
(Osuch et al., 1999, p. 339). These six factors reportedly account for 85% of the
variability (R2= .85)
Reliability. The SIMS showed high internal consistency as assessed by
Cronbach’s alpha (a = .96, n = 99), split-half reliability (r = .92, n = 99, p < .001), and
Guttman split-half reliability (r = .95). Test-retest reliability was adequate after a mean
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interval o f 3.5 weeks (r = .70, n = 32,p < .001) (Osuch et al., 1999). Cronbach’s alphas
coefficients for the individual subscales ranged from 0.81 to 0.93.
Validity. Convergent validity was established by correlating frequency of self-
injury with scores on the Dissociative Experiences Scale (R = .70, n = 93,p< .001), Beck
Depression Inventory (R = .60, n = 90, p < .001), and the Davidson Trauma Scale (R =
.40, n = 80, p < .005). In addition, the SIMS-2 was significantly correlated with
frequency o f self-injury {R = .57, n = 9 9 ,p < .001).
The SIMS-2 evidences good criterion-related validity as respondents with high
SIMS-2 scores (95 or higher) were significantly more likely to: (a) utilize at least two
methods (p < .01), (b) receive medical attention for their SIB (p < .05), (c) feel relieved
by SIB (p < .01), and (d) be in the pathological range on MCMI-II measures of avoidant,
passive-aggressive, self-defeating, schizotypal, and borderline character traits (Osuch et
al, 1999).
Summary. The SIMS-2 is intended for use with non-psychotic adult psychiatric
populations. Ousch et al. (1999) suggests that the SIMS-2 might be useful not only as a
research tool, but also as a treatment outcome measure. The advantages of the SIMS-2
are its (a) ability to convert motivation for self-harm into a quantifiable variable, (b)
comprehensive coverage of the motivation for self-harm dimension, (c) strong
methodological development, and (d) strong reliability (i.e., internal consistency, split-
half reliability, test-retest reliability) and validity (i.e., factor analytic, convergent).
Several identified areas for improvement include: (a) administration to additional
samples, (b) evaluation of its test-retest reliability, (c) discriminant validation with
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alternate self-harm measures, (d) evaluation of its predictive validity, and (e) further
factor analytic evaluation with publication of the empirical data.
Reference. Osuch, E. A., Noll, J. G., & Putnam, F. W. (1999). The motivations for
self-injury in psychiatric inpatients. Psychiatry, 62, 334-346.
Clinician-Administered Detection Instruments
Reviewed in this section are clinician-administered instruments. These
instruments typically consist of semi-structured interviews. Semi-structured interviews
allow the administrator to reword questions or ask additional questions to clarify
responses. These interviews therefore allow for clinical judgment in seeking clarification
o f responses. An evaluation of the ease of administration is beyond the scope of this
review. Rather, this review is focused solely on the psychometric properties of these
semi-structured interviews in the assessment of self-harm behavior.
Self-Injury Interview (SII)
Description. The SII (McKay, Greiner, Greisberg, Napolitano, D’Andrea, &
Hoffman, 2000) is an 11-item, clinician-administered interview designed to assess self-
injury within the past year and to quantify the severity of that behavior. The interview
begins with questions about the presence of self-injury without the intent to die.
Respondents are queried about current or past engagement in 19 specific types of self-
injury, age of onset, and age at last occurrence. These items are not scored, but provide a
context upon which to rate the remaining items. In the second part of the interview,
respondents are asked specifically about: (a) frequency of self-injury, (b) total number
incidents, (c) perception of urges to self-injure, (d) percentage of time urges to self-injure
are acted upon, (e) perception of pain during self-injury, (f) relief following self-injury,
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and (g) whether self-injury occurred during intoxication. These items are scored on a 5-
point Likert scale, with total scores ranging from 0 to 35.
Operational definition. Self-injury is defined as behaviors where physical harm is
engaged in without the intention to commit suicide. Self-injurious acts that were
undertaken with the intent to commit suicide or only while intoxicated were not
considered to be self-injurious behavior for the purposes of this study. In this way, self-
injury is conceptualized as a trait-like behavior that manifests under conditions of stress.
Development/samples studied. The SII was developed on a sample of 24
psychiatric inpatients diagnosed with borderline personality disorder (McKay et al.,
2000). No other information is available regarding this sample. The SII has subsequently
been administered in two studies. In 2003, the SII was administered to a mixed sample
(16 respondents with diagnoses of BPD, 16 with diagnoses of another personality
disorder other than BPD, and 16 controls with no history of psychiatric conditions or
treatment); (Napolitano, 2003). Additionally, McKay, Gavigan, and Kulchycky (2004)
administered to the SII to 48 female inpatients being treated for borderline personality
disorder.
Reliability. The SII has been shown to have internal consistency coefficients
ranging from adequate to high (r = .79, McKay et al., 2000; a =.83, Napolitano, 2003)
and high interrater reliability {ICC - .76). Test-retest reliability was found to be adequate
(r = .87, Napolitano).
Validity. McKay et al. (2004), citing unpublished data, note that the SII evidences
adequate convergent validity with self-injury incidents (r [32] = 0.67, p < .001). The
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predictive validity was assessed by Napolitano (2003) who found that the SII was
predictive of the severity of borderline symptoms.
Summary. The SII was intended for use with adult psychiatric populations, but
whether it was designed for research or clinical purposes is unclear. However, its clinical
utility is limited by its forced-choice format and poorly established validity. However, the
inclusion of self-harm ideation is unique and is analogous to questions regarding suicidal
ideation. This is the only study reviewed that includes reference to self-harm ideation in
the absence of self-harm behavior, which may aid in making distinctions between self-
harm behaviors and self-harm ideation.
Several areas for improvement were identified. First, limited information
regarding the development and validation of the SII was available. All reported
psychometric data reported within this review were generated from two unpublished
studies. Secondly, the operational definition includes "overdose with no lethal intent" and
"not taking care of serious medical condition resulting in tissue damage" as self-injury.
These are two problematic behaviors are not typically considered deliberate self-harm
behavior.
Reference. McKay, D., Greiner, L., Greisber, S., Napolitano, L., D'Andrea, &
Hoffman. (2000). The Self-Injury Interview. (Unpublished measure).
Parasuicide History Inventory (PHI)
Description. The PHI (Linehan, Wagner, & Cox, 1983) is a 48-item,
semistructured, clinician-administered interviewed designed to assess several dimensions
of parasuicidal episodes including: (a) topography, (b) intent, (c) medical severity, (d)
social context, (e) reasons for parasuicide, (f) precipitating and concurrent events, and (g)
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outcomes for all parasuicidal episodes. Parasuicide episodes can refer to single events or
clusters o f events that are either too repetitive or too close together in time to discriminate
as separate acts. The interview can be tailored to target specific periods of time ranging
from lifetime prevalence to particular intervals. The semistructured nature of the PHI
allows questions unnecessary for a given purpose to excluded and allows interviewers to
move freely within the interview.
The PHI contains a complex coding and scoring system that for each parasuicide
episode results in several factor scores including: (a) suicidal intent, (b) instrumental
intent, (c) medical risk, (d) impulsivity, (e) hedonism, (f) functional consequences, (g)
emotional relief, and (h) dissociative. In addition, the absolute total number of
parasuicide acts can be computed by adding the individual acts within each cluster to the
number of single episodes (Linehan, Armstong, Suarez, Allmon, & Heard, 1991).
Operational definition. Parasuicide refers to all nonfatal self-injurious behavior
with clear intent to cause bodily harm or death (i.e., both the behavioral act and the
injurious outcomes are not accidental) that results in actual tissue damage illness or risk
of death or serious injury (Kreitman, 1977). Linehan (1986) proposed three categories of
parasuicidal acts (i.e., suicide attempts, ambivalent suicide attempts, nonsuicidal self-
injury that "differ on the relative intensity and clarity of the intent to die and expectation
of death” (Brown, Comtois, & Linehan, 2002, p. 198). Suicide attempts, whether
unambiguous or ambivalent, are characterized by intentional behavior with either intent
to die or expectation (certain or ambivalent) of death. In contrast, nonsuicidal self-injury
is characterized by intentional self-injury with no (or minimal) suicide intent or
expectation of death (Brown et al.).
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Development/samples studied. Minimal data has been published regarding the
development and psychometric evaluation of the PHI. However, in a review of the PHI,
Brown (2000) reports that the PHI was “constructed to be content valid by including
questions requesting the full range of self-injury characteristics included in other standard
interviews, questionnaires, and suicide risk measures” (p. 18). Additionally, Brown
(2000) reports that the PHI was initially administered to a sample of 166 psychiatric
inpatients either admitted for suicide attempts (n = 77) or who had previously attempted
suicide (n = 89).
Brown and colleagues (2002) reported that the 29-items included in the “reasons
for self-injury” subscale of the PHI were generated from unstructured interviews with a
separate sample of 51 psychiatric inpatients admitted for parasuicide. Based on expert
consensus, 22 of the reasons were clustered into four rationally derived scales: Emotion
Relief (6 reasons), Interpersonal Influence (8 reasons), Avoidance/Escape (5 reasons),
and Feeling Generation (3 reasons); (Brown et al.). The remaining 7 reasons were each
considered unique and were not clustered.
The PHI has been used as an outcome measure in randomized clinical trials (e.g.,
Linehan et al., 1991; Linehan, Heard, & Armstrong, 1993) and been found to be
associated with changes in the frequency, treatment, medical risk, and suicidality of self-
injury behaviors in patients with borderline personality disorder.
Dimensionality. The factor structure of the PHI was reported by Brown (2000) as
consisting of four factors: Suicide Intent, Medical Risk, Impulsivity, and Instrumental
Intent. Three o f the PHI factors (i.e., Suicide Intent, Medical Risk, Impulsivity) represent
characteristics commonly associated with lethality of parasuicide. The fourth factor,
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Instrumental Intent, represents behaviors commonly labeled by others as “suicide
gestures” or non-lethal parasuicide designed to gamer attention from others. However,
Linehan (1996) noted that four additional factors have been proposed: Hedonism,
Functional Consequences, Emotional Relief and Dissociative.
Reliability. The internal consistency of the four original factors (i.e., Suicide
Intent, Medical Risk, Impulsivity, Instrumental Intent) has been established with
Cronbach’s alpha coefficients ranging from .64 to .86 (Brown, 2000). Average interrater
reliabilities for the original four factors range from .59 to .91 over four-month periods.
The overall average of interrater reliability estimates is .80 (Brown). In addition, high
interrater agreement on the Suicidal Intent subscale (k = .85) was found in a study of
borderline women (Brown et al., 2002).
Brown et al. (2002) conducted an examination of the reliability o f their
classification of reasons for parasuicide. Two independent expert raters reclassified the
initial 29 items into one of the four proposed scales. The independent raters agreed with
the original classification for 100% of the Emotion Relief items, 80% of the Interpersonal
Influence items, 89% of the Avoidance/Escape items, and 66% of the Feeling Generation
items. Alpha coefficients for the scales ranged from a low of .36 for Avoidance/Escape to
a high for .77 for Interpersonal Influence (.65 for Emotion Relief, .70 for Feeling
Generation).
Validity. The convergent Validity of the PHI was assessed by comparing the
frequency counts of the PHI to medical records. Agreement was estimated to range from
72% to 86% (Brown, 2000). In addition, PHI ratings of the lethality of the method used
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and the severity of physical condition following parasuicide are highly correlated with
physician ratings of the same events (r = .95 for both ratings) (Brown et al., 2002).
Summary. The PHI is a comprehensive and flexible assessment of self-injurious
behaviors. It is intended for research and clinical use with adult patients with histories of
suicide and diagnoses of borderline personality disorder (Brown, 2000). It has several
strengths including: (a) its assessment of both suicidal and non-suicidal self-injury, (b)
evidence of its sensitivity to change over time, (c) a comprehensive scoring system, (d)
its comprehensive coverage of multiple dimensions of self-harm, and (e) its strong factor
analytic structure.
Areas for improvement include: (a) the need for published original psychometric
data, (b) its over comprehensiveness, (c) the breadth of behaviors that are included under
the rubric o f parasuicide, and (d) the need for continued convergent and discriminant
validation.
Reference. Linehan, M. M., Wagner, A. W., & Cox, G. (1983). Parasuicide
History Interview: Comprehensive assessment of parasuicidal behavior. Unpublished
manuscript. University of Washington, Seattle.
Lifetime Parasuicide Count (LPC)
Description. The LPC (Linehan & Comtois, 1997) is a 16-item, semistructured,
clinician-administered interview designed to measure lifetime history of self-injurious
behaviors grouped by method, intent to die, and level of medical treatment. The first
section of the LPC is intended to elicit information regarding the medical severity and
suicidal intent of the first, most recent, and most severe parasuicidal incident. In addition,
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respondents are encouraged to provide a quick synopsis of the method, intent, and
consequences of these three episodes (first, most recent, and most severe).
The second section of the LPC is intended to elicit a more detailed description of
self-harm behaviors. Respondents are asked specifically about whether they have engage
in 12 different types of self-harm behavior including: cutting, overdosing, burning,
hanging, jumping from high places, shooting, swallowing poisons, smothering, drowning,
stabbing, hitting head, and other. The frequency of each method of parasuicidal behavior
is recorded by intent (i.e., suicidal, ambivalent, non-suicidal) and highest medical severity
(i.e., none, doctor visit, emergency room, medical unit admission, intensive care unit
admission). For statistical analyses, LPC scores represent the total number of reported
self-harm episodes.
Operational definition. The LPC operationally defines parasuicide as any nonfatal
self-injurious behavior with clear intent to cause bodily harm or death that results in
actual tissue damage, illness, or risk of death (Kreitman, 1977). The term parasuicide is
“intended to serve as a broad term describing all non-fatal self-injurious behavior with
clear intent to cause bodily harm or death, thereby reserving attempted suicide for
situations in which intent is known” (Welch, 2001, p. 369). Respondents are given a brief
standardized description of the definition of self-injurious behavior prior to collection of
data.
Development/samples studied. The LPC was initially developed to study adult
parasuicidal females with diagnoses of borderline personality disorder (Comtois &
Linehan, 1999). The initial administration sample consisted of inpatient females ranging
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in age from 18-45. However, the LPC has also been used to assess Latino and African-
American adolescents receiving outpatient psychiatric services (Velting & Miller, 1999).
Verheul, Van Den Bosch, Koeter, De Ridder, Stijnen, and Van Den Brink (2003)
use the LPC as an outcome measure in a randomized controlled study examining the
effectiveness of Dialectical Behavior Therapy (DBT) as compared to treatment as usual
(TAU). Participants included 58 outpatient females diagnosed with borderline personality
disorder. They found an interaction effect for time (i.e., baseline, 22-week, 52-week) and
treatment condition (t (1, 44.4) = 10.24,p < .01, n = 50) resulting in greater reductions in
self-mutilating behavior for the DBT treatment condition.
Bohus et al. (2004) used the LPC as an outcome measure in a randomized
controlled study examining the effectiveness of DBT as compared to a naturalistic
waitlist condition. Participants included 50 outpatient females diagnosed with borderline
personality disorder. At four month follow-up more patients in the DBT condition, as
compared to the waitlist condition (62% versus 31%, respectively), abstained from self-
harm (x2 = 3.11;p < .05).
Reliability. No published reliability data were located.
Validity. No published data regarding the assessment of validity were located.
Summary. Limited information was available regarding the LPC and most
information was obtained through secondary sources. The LPC is intended for use with
adult and adolescent psychiatric samples. Strengths of the LPC include (a) evidence of
predictive validity, (b) a visual summary of method, intent, and highest medical severity
of parasuicidal behavior, and (c) the use of the LPC as a treatment outcome measure.
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Areas for improvement include: (a) the lack of psychometric data regarding its
reliability and validity, (b) the inclusion of a breadth of behaviors not typically
considered deliberate self-harm, and (c) published information regarding the development
and evaluation of the LPC.
Reference. Linehan, M., & Comtois, K. (1997). Lifetime Parasuicide Count.
Unpublished instrument. University of Washington, Seattle, WA.
Instruments for Assessing Severity of Self-Harm Behavior
This section of the review focuses on instruments developed for assessing the
severity of deliberate self-harm behavior. There are relatively few severity assessments
for deliberate self-harm behavior. However, there are several important reasons for trying
to assess the severity of deliberate self-harm behavior.
First, severity of deliberate self-harm behavior may have predictive as well as
descriptive utility. In this context, it is important to determine whether the severity of
deliberate self-harm behavior has predictive validity as well as incremental validity (i.e.,
the clinical characteristics add important non-redundant information to the ability to
predict future behavior). Second, clinicians may want to incorporate information about
severity into of deliberate self-harm behavior into their treatment-planning process. In
this vein, it would be important to show that severity of deliberate self-harm behavior is
related to the course of therapy or outcome response. A third reason for assessing the
clinical characteristics of deliberate self-harm behavior is descriptive in nature.
Information about severity may help clinicians and researchers communicate efficiently
about the similarities and differences of specific deliberate self-harm behaviors.
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Self-Inflicted Injury Severity Form (SIISF)
Description. The SIISF (Potter et al., 1998) is a 7-item, clinician-administered
instrument designed to assess the lethality of life-threatening self-inflicted injury with no
consideration of intent or rescue potential. Self-inflicted injuries are classified according
to method into the following categories: (a) gunshot; (b) jumping or blunt trauma; (c)
hanging; (d) suffocation or drowning; (e) laceration/stabbing; (f) ingestion, inhalation, or
injection of lethal substances; and (g) other. Injuries are then classified, according to
lethality, on either a three or four-point Likert scale. For example, injuries resulting from
laceration/puncture are classified as (a) wound not requiring sutures; (b) wound requiring
sutures, but no damage to arteries, tendons, or large veins; (c) wound resulting in damage
to arteries, tendons, or large veins; or (c) wound penetrating body cavity or major organ.
Operational definition. The SIISF operationally defines near-lethal suicide
attempts as those where “(1) the attempter was likely to have died from suicide had he or
she not received emergency medial or surgical intervention, or (2) the attempter
unequivocally employed a method with a high case fatality ratio (i.e., gunshot wounds
and hanging), in which act the attempter sustained an injury of whatever severity” (Potter
etal., 1998, p. 175).
Development/samples studied. The SIISF was validated on a sample of 715
patients seen in emergency room settings for self-inflicted injuries (Potter et al., 1998).
The sample was predominately female (58%) and Caucasian (60%). Respondents fell into
three broad age groups ranging from 13-to-17 (16%), 18-to-24 (39%), and 25-to-34 (45
%) years of age.
89
Reliability. Potter and colleagues (1998) examined the interrater reliability of
several SIISF ratings, and found excellent interrater agreement for classification of
method of self-injury (k = .94, n = 295), as well as for determination of case status using
the classification of “near-fatality” (£=.93). In addition, adequate interrater agreement
was found for severity of injury ratings associated with laceration/stabbing (k = .71) and
ingestion (k = .73 for level of consciousness; k = .78 for physiological symptoms).
Validity. The convergent validity of the SIISF was established by showing a high
rate of agreement between ratings of method of self-injury on the SIISF and the Risk-
Rescue Rating Scale (K = .88; Potter et al., 1998). In addition, the SIISF was found to
distinguish between more severely injured patients from less severely injured patients
when compared to similar ratings on the Risk-Rescue Rating Scale (Potter et al.).
Summary. The SHFS is intended for use as a medical screening tool with adults in
primary care/emergency room settings. While the SIISF is intended for classifying the
lethality of “near fatal” suicide attempts it has several properties that suggest it may be
useful in classifying all forms of self-injury. Strengths include: (a) the SIISF describes
and classifies physical injuries regardless of suicidal intent thereby avoiding complicated
theoretical distinctions between suicidal and parasuicidal behavior, (b) its ability to
discriminate between patients with minor and life-threatening injuries, (c) a high degree
of interrater reliability, and (d) strong evidence of its convergent validity.
Areas for improvement include: (a) published data regarding its item
development, and (b) the potentially invasive nature of examining wounds, which might
preclude use in clinical research.
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Reference. Potter et al. (1998). Identification of nearly fatal suicide attempts: Self-
Inflicted Injury Severity Form. Suicide and Life-Threatening Behavior, 28, 174-186.
Self-Injury Trauma Scale (SIT)
Description. The SIT (Iwata, Pace, Kissel, Nau, & Farber, 1990) is a clinician-
administered instrument designed to classify and quantify surface tissue damage caused
by self-injurious behavior. The SIT scale permits differentiation o f self-injurious
behavior (SIB) according to topography, location the injury on the body, type of injury,
number of injuries, and estimate of severity. The SIT can be divided into three sections
based upon the information collected and the ratings made.
The first section involves the identification and description each type of SIB
exhibited by the patient (i.e., biting, scratching, etc.), including evidence of healed
injuries. The second section involves documentation of the number, type, and severity of
worst wound at each bodily location. Number of self-inflicted wounds are classified on a
3-point Likert scale: 1 = one wound, 2 = two to four wounds, 3 = five or more wounds.
Classification by type of injury yields two categories: abrasions/lacerations (AL) and
contusions (CT). Severity of worst wound is classified on a 3-point Likert scale: 1 = local
swelling only or discoloration without swelling, 2 = extensive swelling, 3 =
disfigurement or tissue rupture. The third section effectively summaries the obtained
information into 2 index scores (i.e., Number Index [NI] and Severity Index [SI]) and an
estimation of current risk based on location and severity of self-inflicted wounds. The NI
provides a 5-point Likert scale ranking based upon the total number o f injuries observed.
The SI provides a 5-point Likert scale ranking based on the relative occurrence of
severity scores in Part II. Finally, the estimate of current risk provides a ranking of low,
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moderate, or high risk based on the single occurrence of certain types of injuries (i.e., an
extensive abrasion or deep laceration results in a rating of high risk).
Operational definition. The authors define self injurious behavior as behavior that
“produces injury to the individuals own body” (Tate & Baroff, 1966, p. 281; cited in
Iwata et al., 1990, p. 99). Behaviors included in the SIT Scale include head banging,
intentional bruising, scratching, picking, biting, eye gouging, pica, vomiting or
rumination, air swallowing, trichotillomania, and other.
Development/samples studied. The authors note that construction of the SIT was
based on four sources o f input: (a) published material on injury classification, (b)
previous experience in the evaluation and treatment of over 200 self-injurious
individuals, (c) application of preliminary versions of the scale with 9 pilot subjects, and
(d) consultation from physicians. The SIT was initially administered to 35
developmentally disabled participants whose ages ranged from 3 to 19 years (Iwata et al.,
1990). It has been subsequently administered to a few additional developmentally
delayed samples (n = 1, McDonough, Hillery & Kennedy, 2000; n = 8, Persel, Persel,
Ashley, & Krych, 1997).
Reliability. Interrater reliability was examined utilizing fifty pairs of
independently scored records after a mean interval of 24 days (range, 7 to 69 days) (Iwata
et al., 1990) The following mean (median) percentage agreement scores were obtained:
overall agreement, 97% (98%); location of injury, 99% (100%); type of injury, 96%
(100%); number of injuries, 89% (100%); and severity of injury, 94% (100%).
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Percentage agreement was also calculated for the three summary scores: Number Index,
90%; Severity Index, 92%; and Estimate of Current Risk, 100%.
Validity. No published data were located regarding validity of the SIT Scale.
Summary. The SIT is intended for use as a clinical assessment tool with
developmentally delayed adult populations. The SIT has many advantages including its:
(a) ability to objectively and reliably measure multiple aspects of surface tissue damage,
(b) applicability to most forms of SIB, (c) ability to quantitatively define variation in SIB,
and (d) the potential use as a treatment outcome measure.
Areas for improvement include: (a) indices scores are a function of several related
factors thereby reducing the amount of information available for any one dimension of
behavior, (b) lack of evidence for incremental validity of assigning risk based on the
actual consequences of the behavior, (d) the lack of published validity data, and (e) no
delineation between suicidal and non-suicidal self-harm.
Reference. Iwata, B. A., Pace, G. M., Kissel, R. C., Nau, P. A., & Farber, J. M.
(1990). The Self-Injury Trauma (SIT) Scale: A method for quantifying surface tissue
damage caused by self-injurious behavior. Journal of Applied Behavior Analysis, 23(1),
99-110.
Summary
Fourteen instruments that were intended to measure aspects of deliberate self-
harm were identified within the literature. These instruments were divided into three
general categories based upon their format and focus. Nine self-report detection
instruments, three clinician administered detection interviews, and two clinician-
administered severity rating forms. Each was reviewed in terms of its general format,
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operational definition, development, sample characteristics, dimensionality, reliability,
and validity. This review was not undertaken with the express purpose of offering
specific recommendations regarding their clinical or research utility. Each instrument has
its own strengths and weakness and instrument selection “should depend primarily on the
specific needs of the clinician or researcher, the intended use of the instruments, and the
assessment of how an instrument compares to other similar instruments” in meeting these
needs (Goldston, 2000, p. 198). The following summary o f the findings is provided as an
aide in selecting the most appropriate instrument.
In terms of the operationally defined constructs, the majority o f instruments
reviewed were designed to measure specific facets of deliberate-self-harm as a unitary
concept (DSHI, SIS, FASM, SIBQ, SIMS-2, SII). While, several instruments include
separate subscales for the assessment of suicide related variables (SHBQ, SIS, PHI,
LPC), several either draw no distinction between self-harm and suicide (SHI, SIQ) or do
not adequately separate out suicidal from non-suicidal self-harm (FASM, SHBS).
Moreover, several instruments included within this review were designed to measure
boarder constructs such as parasuicide (PHI, LPC) or failed suicide attempts (SIT,
SHFS). These instruments were include within the review because they provide
information relevant to measuring deliberate self-harm. For instance, while the SIT and
SHFS are used to quantitatively and qualitatively evaluate the level of damage for suicide
attempts their format and structure make them ideal for evaluating the severity of
observable deliberate self-harm. Table 1 provides a brief comparison of each instrument
in terms of their length, format, scoring system, item development, and operational
definition.
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Table 1
Instrument Descriptions
Instrument Format Population Scoring Item Selection Operational

System Definition
DSHI Self-report Adult Subscale Clinical observations Direct

Non-psychiatric Continuous Patient feedback Intentional
Literature review Non-suicidal
SHBQ Self-report Adolescent Subscale Not Reported Intentional

Adult Continuous
Non-psychiatric
SHI Self-report Adult Total scale Expert opinion Intentional

Non-psychiatric Continuous Literature review
Psychiatric Subscale
Continuous
SIS Self-report Adolescent Not reported Literature review Direct

Adult Intentional
Psychiatric Non-suicidal
FASM Self-report Adolescent Subscale Patient feedback Direct

Non-psychiatric Continuous Literature review Intentional
Psychiatric Non-suicidal
SIQ Self-report Adult Not reported Not reported Direct

Psychiatric Intentional
SHBS Self-report Adult Not reported Not reported Direct

Non-psychiatric Intentional
Psychiatric
SIBQ Self-report Adult Total scale Literature review Direct

Non-psychiatric Continuous Intentional
Non-suicidal
SIMS-2 Self-report Adult Total scale Literature Review Direct

Psychiatric Continuous Intentional
Non-suicidal
SII Interview Adult Subscale Not reported Direct

Psychiatric Continuous Intentional
Non-Suicidal
PHI Interview Adult Total scale Not reported Intentional

Psychiatric Continuous Non-suicidal
Partial Scale
Continuous
{table continues)
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Instrument Format Population Scoring Item Selection Operational
System Definition
LPC Interview Adolescent Not reported Not reported Intentional

Adult Non-suicidal
Psychiatric
SIISF Interview Adolescents Not reported Not reported Direct

Adults Intentional
Psychiatric
SIT Interview Children Subscale Clinical Direct

Adolescents Ordinal observations Intentional
Psychiatric Expert opinion
Literature review
Note. DSHI = Deliberate Self-Harm Inventory. SHBQ = Self-Harm Behavioral Questionnaire. SHI = Self-
Harm Inventory. SIS = Self-Injury Inventory. FASM = Functional Assessment o f Self-Mutilative
Behaviors. SIQ = Self-Injury Questionnaire. SHBS = Self-Harm Behavior Survey. SIBQ = Self-Injurious
Behaviors Questionnaire. SII = Self-Injury Interview. PHI = Parasuicide Count. LPC = Lifetime
Parasuicide Count. SIISF = Self-Inflicted Injury Severity Form. SIT = Self-Injury Trauma Scale. SIMS =
Self-Injury Motivation Scale.
The data in this table are referenced from multiple sources, which are cited within each individual measures
review section.
In terms of the intended populations for use, the majority of instruments reviewed
were developed and validated for use with adult respondents (DSHI, SHI, SIQ, SHBS,
SIBQ, SIMS-2, SII, PHI). Four instruments have been validated for use with both adults
and adolescents (SHBQ, SIS, LPC, SIISF) and two instruments are intended for use with
adolescents and children (FASM, SIT). Additionally, three of the instruments were
developed and validated with nonclinical samples (DSHI, SHBQ, SIBQ), eight with
clinical samples (SIS, SIQ, SIMS-2, SII. PHI, LPC, SIISF, SIT), and three with both
clinical and nonclinical samples (SHBQ, SHI, FASM). Table 1 provides a concise
summary o f each instruments developmental samples.
The content validity of each instrument is difficult to evaluate as no guidelines
exist regarding the central domains that comprise the construct of DSH. However,
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examination of the method of item generation and selection provides limited insight into
content validity. For seven of the instruments (SHBQ, SIQ, SHBS, SII, PHI, LPC, SIISF)
no information was available regarding their initial development. The remaining seven
instruments based their item generation and selection on a combination of reviews of the
relevant literature (DSHI, SHI, FASM, SIS, SIBQ, SIMS-2, SIT), patient feedback
(DSHI, FASM), expert opinion (SHI, SIT), and clinical observations (DSHI, SIT). Table
1 provides a summary of the item selection of each instrument.
The psychometric evaluation of instruments is based upon the presupposition that
some form of quantitative data exists. However, in reviewing the available instruments a
wide variety of scoring systems ranging from none to continuous measures of both
numerical and qualitative data exist. In fact, five instruments have no reported scoring
systems (SIS, SIQ, SHBS, LPC, SIISF), though researchers often create adhoc frequency
counts for statistical purposes. Four instruments include comprehensive total-scale
scoring systems (SHI, SIBQ, PHI, SIMS-2) and five include partial subscale scoring
systems (DSHI, SHBQ, FASM, SII, SIT). Accordingly, the method and quality of
psychometric evaluation of these instruments is highly variable.
In terms of reliability estimates for the reviewed instruments, three of the self-
report detection instruments (DSHI, SIBQ, SIMS-2) have adequate to excellent internal
consistency and test-retest reliability estimates, suggesting that their scale items are
measuring the same construct in a replicable manner. Three of the self-report instruments
(SHI, SIS, FASM) have adequate to excellent internal consistency estimates, but lack
evaluation of their test-retest reliability. Three of the instruments (SIQ, SHBS, LPC) have
no published reliability estimates, making their research utility questionable. All four of
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the clinical administered interviews (SII, PHI, SIISF, SITS) have adequate to excellent
inter-rater reliabilities. Two of these instruments (SII, PHI) have adequate to high internal
consistency and inter-rater reliabilities; however only the SII has been evaluated for
internal consistency, test-retest, and inter-rater reliabilities. Table 2 provides a summary
of the estimates of reliability for each instrument.
Evaluations of the instruments validity coefficients reveals the following general
characteristics. Three of the instruments have been factor analyzed (SHBQ, FASM,
SIMS-2) providing evidence of stable dimensional structures. Nine instruments (DSHI,
SHBQ, SHI, FASM, SIBQ, SIMS-2, SII, PHI, SIISF) have been evaluated for their
convergent validity, though criterion measures vary in the quality of their psychometric
properties and theoretical connection with deliberate self-harm. Two instruments have
been evaluated for their discriminant validity (DSHI, SIBQ), though the DSHI proved to
be significantly correlated with its criterion measures and the SIBQ was compared to a
measure o f verbal ability that has a tenuous theoretical relationship with self-harm. Table
3 provides a summary of the estimates of validity for each measure.
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Table 2
Instrument Reliability Estimates
Instrument Internal Consistency Test-Retest Inter-Rater
DSHI Total scale: Presence o f self-harm: None

a=.82 0=.68,/?<.OOl
X=3.3 weeks
# o f behaviors:
/-=.92,/?<.001
X=3.3 weeks
SHBQ Factors: None Total scale:

Self-Harm; oc=.95, rj(=.88-.95 £=.95
Suicide
Attempts; a=.96, ru=.19-.91
Threats; a=.94, r„=.68-.91
Ideation; a=.89, r,,=.65-.90
SHI Total scale: None None

a=.93, n=226
SIS Subscale: None None

Indirect self-harm; a=.68
Direct self-harm; a=.76
FASM Factors: None None

Self-Harm
Moderate; r=.65
Severe; r=.66
Reinforcement
Automatic negative; a=.62
Automatic positive; a=.69
Self negative; a=.76
Self positive; a=. 85
SIQ None None None
SHBS None None None
SIBQ Total scale: Total scale: None

a=. 84 0= 78, /K.OOl
n=16,X=3.9 weeks
SIMS-2 Total scale: Total scale: None

a=.96, n=99 r=.70,p<.001
Split-half; r=.92,p<.001, n=99 n=32,X=3.5 weeks
Guttman split-half; r=.95
Factors:
a=.81 to .93
{table continues)
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Instrument Internal Consistency Test-Retest Inter-Rater
SII Total scale: Total scale: Total scale:

a=. 83 R=. 87 ICC=.76
r=.79
PHI Factors: Factors:

A=. 64 to .86 k=.59 to .91, X=4 months
mean £=.80
LPC None None None
SIISF None None Classification o f method:

£=.94, «=295
Determination o f status:
£=.93
Severity o f injury ratings:
laceration/stabbing; £=.71
ingestion:
consciousness; £=.73
symptoms; £=.78
SIT None None Mean percentage agreement:

50 protocols, X=24 days
Overall agreement =.97
Location o f injury = .99
Type o f injury =.96
Number o f injuries =.89
Severity o f injury =.94
Summary Scores:
Number index =.90
Severity index =.92
Current risk index =.10
review section.
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Table 3
Instrument Validity Estimates
Instrument Factorial Convergent Discriminant
DSHI None Borderline Personality Suicide attempts:

Organization: r = .20, p < .05
r = .48,/> < .001 History o f therapy:
r = .21,/) < .01
Social desirability:
r = .21, p < .05
SHBQ Factors: Suicide Assessments: None

Self-harm (2=2.03) r = .34, p < .001
Suicide attempts (2=1.51) r = .35, p < .001
Suicide threat (2=1.96) r = .27, p < .001
Suicidal ideation (2=1.42)
SHI None Borderline Personality None

Organization:
r = .76, p < .01, « = 221
r = .13, p < .01, n = 221
r = .51, p < .01, n = 285
r = .65, p < .01, n = 18
Nonadaptive and Adaptive
Personality Traits:
Self-harm (r = .61, p < .001)
Antisocial (r = .40, p < .001)
Borderline (r = .55, p < .001)
Narcissistic (r = .27, p < .01)
SIS None None None
FASM IFI = .91, CFI = .90 Presence o f Self-harm: None

RMSEA = .05 (CI90%= .03-.07) Depression; F = 1 3 9 , p < .01
X2/d f= 1.41 Hopelessness; F = 8.24, p < .01
Reinforcement Factors: External anger; F = 11.88, p <.01
Automatic Negative (ANR) Risk taking; F = 16.31 , p < .01
Automatic Positive (APR) Suicide attempts:
Self Negative (SNR) ANR factor; p = .22, p < .05
Self Positive (SPR) PTSD symptoms
APR factor; p = .29, p < .01
MDD symptoms:
APR factor; /? = .36, p < .01
SNR factor; p = .24, p < .001
SPR factor; p = .40, p < .001
Hopelessness:
ANR factor; P = .25, p < .01
Social perfectionism:
SNR factor; /? = .23, p < .001
SPR factor; P = .30, /? < .01
(table continues)
101
SIQ None None None
SHBS None None None
SIBQ None Alexithymia: Verbal ability:

r = .448, p < .01, h = 100 r = -.015,/? > .05, n
r = .266, p < .01, n = 109 = 109
SIMS-2 F? = .85, N = 99 Frequency o f Self-Injury: None

Factors: Total Scale
Affect modulation (AM) R = .57,/? < .001, «= 99
Desolation (D) Dissociation
Punitive duality (PD) Total scale
Influencing others (IO) R = .70, p < .001, « = 93
Magical control (MC) Factors
Self-stimulation (SS) PD; R = .77, p < .001, « = 93
IO; R = .34, p < .01, h = 93
Depression
Total Scale
R = .60, p < .001, n = 90
Factors
PD; 7? = .64,/? < .001, h = 90
IO; R = 3 2 , p < .01,« = 90
History o f Trauma:
Total Scale
R = .40, p < .01, « = 80
Factors
AM; R = .43,/? < .001, « = 80
Amnesia for SIB:
Factors
PD; r = .36, p < .01, « = 74
Feelings o f relief:
Factors
AM; r - .35, p < .01,« = 74
PD; r = .31, p < .01, n = 74
SII None Self-injury incidents: None

r (32) = 0.67,p < .001
PHI Medical records: None

Frequency; r = .72 to .86
Physician ratings:
Lethality o f method; r = .95
Severity o f injury; r = .95
LPC None None None
{table continues)
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SIISF None Lethality o f method None
00
00
II
SIT None None None
review section.
103
CHAPTER V
DISCUSSION
This chapter includes: (a) an overview of the study, (b) assumptions and
limitations of the study, (c) discussion of the findings, (d) implications of the findings, (e)
impediments to the field, and (f) concluding remarks.
Overview of the Study
The purpose of this review of the literature was to describe and critique the most
relevant and widely used instruments of deliberate self-harm. The results of this review
provide clinicians and researchers with a compendium of information regarding the
strengths, weaknesses, and psychometric properties of commonly used scales. This
information can be used to evaluate existing findings, clarify methodological
inconsistencies, and develop future instruments.
Assumptions and Limitations
Two fundamental assumptions underlie this study. First, emphasis is placed on
science-informed practice and correspondingly, a high importance is placed on
psychometric evidence of reliability and validity. This is markedly one-sided as many
measures based on face validity and clinical utility may actually be more clinically useful
measures of the construct. However, the tendency to continuously create, modify, and
utilize unpublished instruments with limited psychometric evaluation inhibits the
scientific advancement of the field.
While great effort was expended in attempting to identify and review all
instruments published or appearing in the scientific and clinical literature of deliberate
104
self-harm, some omissions likely occurred in light of the time-limited nature of the
review. In addition, several measures (e.g. Ottawa/Queen's Self-Injury Questionnaire,
European Parasuicide Study Interview Schedule, Self-Harm Information Form) though
mentioned in published research, were not able to be identified, obtained, or reviewed.
Also, review of pending psychometric data for several measures (i.e., SIQ, SII, FASM,
PH, LPC) were not available for analysis. Therefore, readers should anticipate future
published updates for these instruments, as well as likely development of new
instruments.
Discussion of the Findings
While, several instruments show promise in accurately measuring specific aspects
of DSH, the instruments reviewed exemplify the variability in psychometric properties
across instruments measuring presumably similar constructs. Many of the instruments
reviewed demonstrated adequate internal reliability and convergent validity, though
others lack proper development, evaluation, or standardization for use.
The results of the review identified several areas of weakness in the measurement
of deliberate self-harm. These areas include: (a) inconsistent use of terminology; (b)
variations in operationally defined behavior; (c) unclear intended purposes of
instruments; (d) scoring systems that omit significant portions of the data collected; (e) a
general lack of measures with discriminant, predictive, or incremental validity; (f) the
lack of instruments with evidence of extended temporal stability or sensitivity to change
over time; (g) the failure to use other measures of deliberate self-harm as criterion
measures; (h) the general failure to move beyond descriptive instruments; and (i) the
failure to publish information regarding instrument development and evaluation.
105
Implications of the Findings
The valid and reliable measurement of deliberate self-harm has become a limiting
factor in the development of an accurate, clinically useful, and effective body of
knowledge. The continued use of psychometrically questionable instruments raises
concerns regarding the internal and external validity of the resulting findings. A
comprehensive critique of the existing research base regarding deliberate self-harm is
beyond the scope of this review. However, the broad implications of the results of this
review will be presented.
The use of multiple instruments with varied terminology, operational definitions,
and intended purposes makes the comparison of findings across studies extremely
difficult (Brown, 2000; Nock & Prinstein, 2004b). The inability to compare findings
among studies inhibits the accumulation of knowledge about deliberate self-harm.
Similarly, the use of instruments with unknown or poorly evaluated psychometric
properties raises questions regarding the internal and external validity of their findings
thus undermining the confidence with which one can rely on the established literature.
The general failure to develop comprehensive scoring systems, which take into
account the quantification of various response formats, has resulted in limitations in the
types of psychometric evaluations that can be conducted. In addition, psychometric
support for one section of an instrument does not correspondingly confirm the
psychometric properties of other sections of the instrument.
The lack of existing instruments to measure change over time (temporal stability
and sensitivity to change), to predict future self-harm behavior (predictive validity), or to
accurately assess severity has severely limited clinically oriented treatment outcome
106
studies and all but precluded longitudinal studies of the disorder. Established assessment
instruments that are sensitive to changes in either the propensity for self-harm or self-
harm ideation are required to determine whether treatment programs are efficacious
(Brown, 2000). The absence of instruments designed for treatment outcome assessment
precludes the valid and reliable assessment of the clinical work being done in the area of
deliberate self-harm. This not only impoverishes the field, but does a great disservice to
the clients seeking effective treatment.
The failure of most measures to move beyond pure description of behavior is a
limiting factor in understanding the psychological processes that underlie the behavior.
Goldston (2000) noted in his review of suicide assessment instruments that "beyond
simply using instruments that assess clinical characteristics...for descriptive purposes,
there is a general need to better understand the significance of those characteristics" (p.
200). This assertion is reflective of the current state of DSH research, which has resulted
in a heterogeneous list of associated diagnostic and psychosocial characteristics, which
adds little to our understanding of why individuals self-harm (Nock & Prinstein, 2004b).
Finally, the failure of many authors to publish information regarding the
development, evaluation, or incremental validity of their measures places a great burden
on consumers of the research in evaluating the validity and applicability of the results.
Moreover, it greatly impedes the continued improvement of the field of measurement of
deliberate self-harm in several ways including: (a) encouraging other researchers to
develop their own measures, (b) laying a precedent for not disclosing instrument
development data, and (c) preventing other researcher from benefiting from previous
successes and failures.
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Impediments to the Field and Suggestions for Future Development
In addition to problems specific to instrument development, evaluation, and
selection, several broader areas of concern exist. These areas of concern are more
inherent in the field and are not likely to be easily rectified, but rather require continued
attention. Each area is accompanied with suggestions for future research and
development.
First, the field lacks a comprehensive lexicon, consistent operational definitions,
and standards/guidelines for research, instrument development, and evaluation. Studies
aimed specifically at the assessment of DSH, which address psychometrics, are greatly
needed.
Second, the lack of consensus regarding the central domains that comprise the
construct of deliberate self-harm is particularly limiting in regards to future research. This
is especially true given the multifaceted, multidetermined, and highly correlated nature of
self-harm. While select instruments measure multiple domains of DSH, no measure to
date measures the entire "construct" of deliberate-self-harm. In fact, most instruments
merely document the presence of specific behavioral manifestations of DSH and are thus
of limited use in their application to research that attempts to move beyond purely
descriptive or basic correlational designs (Le & Paivio, 2004).
Third, certain aspects of DSH are harder to measure than others. For instance,
measuring the etiology, motivation, function, intent, and severity of deliberate self-harm
are highly subjective phenomenon that are reliant on self-report. Reliance on self-report
data raises two major concerns (i.e., social desirability and distortions of retrospective
recall); (Nock & Prinstein, 2004b). Ascertaining the impact of these two factors is
108
difficult as the secretive nature of the behavior leaves few alternative methods of data
collection. However, several studies suggest the use of self-report assessment measures
are quite accurate for sensitive topics such as suicide related behaviors (Hurt, Hyler,
Frances, Clarkin, & Brent, 1984; Kaplin, Asnis, Sanderson, Keswant, De Lecuona, &
Joseph, 1994). Moreover, several studies suggest that self-report measures may be more
accurate than clinical interviews because they are standardized, respondents are less
constrained by social desirability, and in research settings it may be easier to assure
participants of the confidentiality of their responses (Erdman, Greist, Gustafson, Taves,
& Klein, 1987; Greist, Gustafson, Stauss, Rowse, Laughren, & Chiles, 1973; Joiner,
Rudd, & Rajab, 1999; Klimes-Dougan, 1998; Levine, Ancill, & Roberts, 1989; Malone,
Szanto, Corbitt, & Mann, 1995; Range & Knott, 1997). If self-report instruments of
suicide are at least equivalent to clinical interviews, then self-report instruments should
prove as useful for the study of deliberate self-harm behavior. However, to date no
studies have compared the accuracy of self-report versus clinician administered
instruments of deliberate self-harm.
Fourth, there is a strong need to develop empirically-supported instruments that
provide both clinically useful and psychometrically sound data. Clinical and research
assessments differ in terms of their context and their aims. While they share some
characteristics (i.e., reliably define and describe client characteristics, sensitivity to
change over time) they differ on others such as their nomothetic versus idiographic
nature. Clinical assessments are primarily idiographic in nature; aimed at describing,
understanding, and intervening with individuals. In contrast, research assessments are
typically nomothetic; developed to describe sample characteristics, and to measure group
109
differences that are amenable to statistical analysis (Rotgers, 2002). Several criteria have
been identified that must be met in order for an instrument to be clinically useful
including: (a) brevity and ease of administration, (b) low cost and easy to obtain and
score, (c) use of non-technical language, (d) ease of interpretation and explanation, (e)
psychometrically reliable and criterion/content valid, (f) predicatively valid, and (g)
sensitive to change (Rotgers). Unfortunately most of the measures developed to date,
whether initially developed as clinically oriented data collection tools or as research
instruments do not meet the above criteria. Psychometrically sound instruments are a
limiting factor in conducting any type of clinically oriented research (Rotgers).
Fifth, the combination of ethical and legal safeguards, practical safety concerns,
and a lack o f established research procedures has resulted in difficulty recruiting adequate
numbers of participants to systematically conduct research (Nock & Prinstein, 2004b). Of
special importance is the notion that inquiring about deliberate self-harm will in fact
elicit, reinforce, or encourage the behavior. To date no studies have examined the effects
of inquiry on future self-harm behavior. However, a study by Hall (2002) examined this
same question in regards to suicidal behavior. She found that the guidelines of the Royal
New Zealand College of General Practitioners, New Zealand Guidelines Group,
American Academy of Family Physicians, United States Department of Public Health
and Human Services, and World Health Organization all contain statements asserting that
inquiry about suicidal intent does not increase risk for precipitating attempts, but an
exhaustive review of the literature resulted in no supporting empirical references. Hall
noted that "despite this lack of literature, it is widely and strongly asserted in many
professional guidelines concerning the management of suicidal patients that no such risk
110
exists" (p. 6). Continued effort is needed in the areas of establishing standardized
research protocols/guidelines for self-harm populations, addressing legal and ethical
issues which often impede successful initiation of research programs, and establishing a
precedent for research in this area are needed.
Sixth, unlike other fields of study that suffer from a lack of independent identity,
the field of deliberate self-harm suffers from too strong of an independent identity. The
examination and extrapolation of relevant questions, paradigms, and methodology
utilized for other fields of study may aide in addressing some of the current
methodological problems the field is experiencing. For instance, several domains of
interest within the field of suicidology would likely benefit the study of DSH, including
the assessment of risk-factors, protective factors, and the assessment of ideation.
Likewise the fields of emergency room medicine and medical triage may offer insight
into developing more appropriate assessments of severity.
Conclusion
A variety of instruments relevant to the study of deliberate self-harm have been
developed. Unfortunately, there has been a failure to focus on the thorough, systematic,
and careful evaluation of the properties and utility of these instruments. Given the
relatively new empirical study of deliberate self-harm there are obviously many
dimensions which need investigation. However, while the development of new
instruments is often a necessity, doing so without careful adherence to established
guidelines of test construction and evaluation is counterproductive. In fact, the current
heterogeneity o f instruments has contributed significantly to the questionable reliability
and validity of the research literature and the continued fragmentation of the field.
Ill
Moreover, given the difficulty with which current instruments reliably and validity
measure fundamental dimensions of deliberate self-harm (e.g., method, frequency,
duration, severity), the unhindered propagation of additional measures is cautioned.
Overall, a strong need exists to develop a narrower, standardized set of measures to use in
research on deliberate self-harm.
While many areas for improvement have been identified, the fact remains that the
instruments reviewed provide both the impetus and the blue-print for future development
in the area of deliberate self-harm measurement. Based upon the results of this review, an
ideal DSH assessment instrument would include: (a) a behaviorally based operational
definition, (b) a comprehensive quantitative scoring system, (c) qualitative follow-up
questions, and (d) comprehensive coverage of vital content areas (i.e., method, frequency,
duration, severity, motivation, precipitating factors, ideation, protective factors, and
history of suicidal.
112
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Lamb 2005 A Systematic Review of Deliberate Self - Harm Assessment Instruments

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Pepperdine University

Graduate School of Education and Psychology

A SYSTEMATIC REVIEW OF DELIBERATE SELF-HARM ASSESSMENT

A clinical dissertation submitted in partial satisfaction

of the requirements for the degree of Doctor of Psychology

All rights reserved.

ProQuest Information and Learning Company

Edward P. Shafi .D., ABPP, Chairperson

Jd$ K. Asaihen, Ph.D.

Robert A. deMayo, Ph.D.

Mg£rgaf£t J. Web&, Ph.D.

All Rights Reserved

CHAPTER 1: PROBLEM STATEMENT...............................................................................1

Purpose and Importance of the Review......................................................................3

CHAPTER II: REVIEW OF LITERATURE......................................................................... 6

Characteristics of Self-Harming Populations............................................................13

Foundations of Deliberate Self-Harm....................................................................... 17

Diagnostic Challenges of Self-harm.........................................................................20

Measurement of Deliberate Self-Harm.................................................................... 31

CHAPTER III: PLAN OF ACTION..................................................................................... 35

Strategies for Identifying Self-Harm Measures.......................................................47

Plan for Evaluating Self-Harm Measures................................................................ 49

CHAPTER IV: INSTRUMENT REVIEW...........................................................................53

Instruments for Assessing Severity of Self-Harm Behavior................................... 88

Overview o f the Study.............................................................................................104

Assumptions and Limitations................................................................................. 104

Discussion of the Findings...................................................................................... 105

Implications of the Findings................................................................................... 106

Impediments to the Field and Suggestions for Future Development....................108

Table 1: Instrument Descriptions................................................................................ 95

Table 2: Instrument Reliability Estimates...................................................................99

Table 3: Instrument Validity Estimates..................................................................... 101

intellectual pursuits; to my grandparents, Russell and Mary Lamb, who generously

Toby F. Lamb, Psy.D.

1999-2005 Pepperdine University, Culver City, CA

1997-1999 New Mexico Highlands University, Las Vegas, NM

1990-1995 San Diego State University, San Diego, CA

2002-2003 Sparks M. Matsunaga Veteran’s Affairs Medical Center, Honolulu, HI

2001-2001 Harbor-UCLA Medical Center, Torrance, CA

2001-2002 Pepperdine University Community Counseling Center, Culver City, CA

2000-2001 Del Amo Hospital, National Treatment Center, Torrance, CA

1999-2000 Pepperdine University Student Counseling Center, Malibu, CA

2003-2005 Doctoral Dissertation

2004-present Co-Principal Investigator

2004-present Assistant Director

1998-1999 Masters Thesis

Research Support and Awards:

2004 Co-Principal Investigator

1999 Student Research Award, APA Division 27

2005-present Los Angeles California Psychological Association

1996-present American Psychological Association

1998-present Psi Chi, The National Honor Society in Psychology

1998-2000 APA Division 27, Society for Research and Action

1998-1999 Graduate Student Representative to the Facuity

1997-1999 Campus Representative, APAGS

1998-1999 Treasurer, Psi Chi

A systematic review and critique of 14 of the most commonly used deliberate

researchers with a compendium of information and critique regarding the strengths,

weaknesses, and psychometric properties of commonly used instruments. While, several

instruments showed promise in accurately measuring specific aspects of DSH, others

lacked proper development, evaluation, or standardization for use. The instruments

dimensions o f deliberate self-harm, the unhindered propagation of additional measures is

cautioned. Methodologically sound instrument development and evaluation is needed