Journal of Psychiatric Research 162 (2023) 57–64

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Journal of Psychiatric Research

journal homepage: www.elsevier.com/locate/jpsychires

Association between alexithymia and non-suicidal self-injury in psychiatric

patients: the mediating role of self-esteem and the moderating role of
emotional intelligence
Zaiquan Dong a, #, Jing Zhou b, #, Aldo Conti c, Samuel J. Westwood d, Xia Fu e, Qi Liu e,
Yanling Yuan f, Xia Huang a, Changjian Qiu a, Xiaohui Zhang g, **, Wanjie Tang a, c, *
a
Mental Health Centre, West China Hospital, Sichuan University, Chengdu, China
b
Department of Psychosomatic Medicine, Leshan People’s Hospital, Leshan, Sichuan, China
c
Department of Child & Adolescent Psychiatry, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
d
Department of Psychology, School of Social Science, University of Westminster, London, UK
e
Out-patient Department of West China Hospital, Sichuan University, Chengdu, Sichuan, China
f
Department of Pharmacy of West China Hospital, Sichuan University, Chengdu, China
g
State Key Laboratory of Oral Diseases, National Clinical Research Centre for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, China

A R T I C L E I N F O A B S T R A C T

Keywords: Background: Raffagnato’s theory claims that if people have no words to express their emotions (alexithymia),
Alexithymia they express themselves by venting or through non-suicidal self-injury (NSSI). However, these associations have
Self-esteem not been confirmed in psychiatric patients. This study explored the relationship between alexithymia and NSSI in
NSSI
psychiatric patients and the potential underlying psychological mechanisms.
Emotional intelligence
Psychiatric patients
Methods: This retrospective study involved face-to-face interviews with 449 outpatients consecutively recruited
from West China Hospital. Alexithymia, self-esteem, NSSI, and emotional intelligence (EI) were measured. The
moderating role of EI and the mediating role of self-esteem between alexithymia and NSSI were also explored.
Logistic regressions were used to examine whether sociodemographic, clinical variables and alexithymia were
independently associated with NSSI.
Results: The DSM-5 NSSI disorder and alexithymia prevalences were found to be 32.5% and 45.2%. When the
other covariables were controlled for, the alexithymic patients were found to be at increased odds (OR 2.76) of
engaging in NSSI behaviors. These results confirmed the strong associations between alexithymia, low self-
esteem, and NSSI risk. Lower EI was found to be related to the connections between alexithymia and NSSI.
Except for the lower risk in anxiety patients, the risk of NSSI was similar for patients with other mental disorders,
Conclusion: This study revealed the psychological mechanisms through which alexithymia increases the risk of
NSSI. Therefore, to reduce NSSI risk, screening for alexithymia should be emphasized. Self-esteem as a targeted
psychological intervention could also assist in mitigating the process from alexithymia to NSSI behaviors, and EI
training for psychiatric patients could weaken the relationship between alexithymia and NSSI.

1. Introduction DSM-5 (American Psychiatric Association, 2013). Although NSSI goes

Non-suicidal self-injury (NSSI) is the deliberate destruction of a
person’s own body tissues without having any suicidal intentions (Gratz
et al., 2015). Even though NSSI has not been officially listed as a mental
disorder, it has been classified as a distinct diagnostic entity in the
against self-protection instincts, people who engage in NSSI are seeking
to temporarily alleviate their intense negative emotions and feelings or
to divert their attention from mental anguish (Klonsky and Muehlen­
kamp, 2007). A recent systematic review by Wilkinson et al. (2022)
reported an association between psychological distress and NSSI in

* Corresponding author. Mental Health Centre, West China Hospital, Sichuan University, Chengdu, China.or
** Corresponding author.
E-mail addresses: tangwanjie2010@gmail.com, tangwanjie@scu.edu.cn (W. Tang).
#
These authors are co-first authors

https://doi.org/10.1016/j.jpsychires.2023.04.006
Received 5 October 2022; Received in revised form 9 March 2023; Accepted 5 April 2023
Available online 12 April 2023
0022-3956/© 2023 Published by Elsevier Ltd.
Z. Dong et al.
young English adults (Wilkinson et al., 2022). Although NSSI rates
fluctuate across studies, lifetime NSSI has been estimated at 5% in
community samples. For example, the estimated lifetime NSSI preva­
lence rate was found to be 4.86% in a nationally representative
face-to-face survey with 7192 adults in England (Liu, 2021), in Scotland,
the lifetime NSSI prevalence was 16.2% in a nationally representative
sample (O’Connor et al., 2018), and a meta-analysis that statistically
pooled the results of previous studies, found the pooled NSSI prevalence
to be 13.4% in young adults and 5.5% in adults (Swannell et al., 2014).
Mannekote Thippaiah et al. (2021) also found that the lifetime NSSI
prevalence rates in developing countries, such as Turkey, China, India,
and Mexico, were comparable to lifetime NSSI prevalence rates in
developed western countries, such as the US, Europe, and the UK.
However, NSSI has been observed to be several times higher in
clinical adult samples than in community samples (Ose et al., 2021). For
example, the weighted average percentage of patients with a lifetime
history of NSSI was 27.3% in people who had eating disorders (Cucchi
et al., 2016), a large nationwide Norwegian survey found that 8.1% of
psychiatric outpatients had experienced at least one NSSI episode in the
previous four weeks (Ose et al., 2021), Kang et al. (2021) found that
around 34.2% of Chinese young adults with major depression had a
history of NSSI (Kang et al., 2021), and a systemic review found that
between 4% and 70% of psychiatric inpatients engaged in self-harming
behaviors (Timberlake et al., 2020). However, few studies have explored
the psychosocial mechanisms underlying NSSI in clinical adult patient
samples, the results from which could provide targeted guidance for
psychological and social improvements to reduce the risk of harm in
vulnerable patients affected by psychiatric disorders. Therefore, to
address this research gap, this study examined the mediating and
moderating relationships between alexithymia, personality traits, and
NSSI.
1.1. Associations between alexithymia and NSSI
As NSSI has been theoretically regarded as an emotional regulation
problem (McKenzie and Gross, 2014), alexithymia, which is an affection
regulation deficiency characterized by emotional expression and iden­
tification difficulties (Taylor et al., 1999), may play a role in NSSI
(Sleuwaegen et al., 2017). Based on the cognitive and emotional deficit
characteristics in patients with psychosomatic illnesses, Nemiah and
Sifneos (1970) first described alexithymia as a “subclinical phenomenon
involving a lack of emotional awareness or, more specifically, difficulty
in identifying and describing feelings and in distinguishing feelings”.
Taylor and Bagby later developed the 20-item Toronto Alexithymia
Scale to assess alexithymic characteristics in three main areas: difficulty
identifying emotions, difficulty expressing emotions, and
externally-directed thinking (Bagby et al., 1994; Taylor et al., 1985).
Past research has shown that alexithymia is closely related to psycho­
pathological and emotional-behavioral problems (Clougher, 2020; Muzi
and Pace, 2020; Pace et al., 2021; Zhang et al., 2022).
Raffagnato’s theory (Raffagnato et al., 2020) claims that patients
who have no words to express their negative emotions (alexithymia) are
more likely to express themselves by venting or hurting themselves
(NSSI). Many empirical and theoretical studies have confirmed that
alexithymia is strongly related to NSSI behavior (Iskric et al., 2020).
Most notably, compared to control groups, significantly higher alex­
ithymia was found in non-psychiatric illness samples that had been
admitted to emergency departments because of self-injury or attempted
suicide (Hsu and Chen, 2013). Adolescent clinical sample investigations
have found alexithymia to be a common attribute of the self-harming
behaviors used to express psychological and emotional problems (Raf­
fagnato et al., 2020). Alexithymia has also been found to be more
prevalent in adolescent outpatients with NSSI behaviors (Gatta et al.,
2016; Miscioscia et al., 2022) and was also found to be a significant NSSI
predictor in a sample of female adolescent inpatients (Lüdtke et al.,
2016). Although many studies have confirmed the link between
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Journal of Psychiatric Research 162 (2023) 57–64
alexithymia and NSSI (Greene et al., 2020; Iskric et al., 2020; Norman
et al., 2020), only a few have examined the possible connections in adult
psychiatric patient samples. For example, alexithymia was found to be
associated with NSSI in borderline personality disorder (BPD) patients
(Sleuwaegen et al., 2017). However, whether this alexithymia and NSSI
relationship holds for adult psychiatric patients needs further
confirmation.
1.2. Mediating role of self-esteem between alexithymia and NSSI
Self-esteem is the overall affective evaluation of one’s own worth,
value, or importance (Blascovich et al., 1991). Bagby et al.’s (1986)
research postulated that alexithymics’ impaired capacity for self-care is
the result of a distorted self-representation that is experienced as feel­
ings of inadequacy and helplessness, which implied that there was a
causal connection from alexithymia to self-deprecation. Therefore,
based on this hypothesis, the current study proposes that self-esteem
could be a possible mediator between alexithymia and NSSI (Luminet
et al., 1999), that is, a negative alexithymic self-belief could be related to
NSSI because of the high correlation with alexithymia, a sense of
worthlessness, and negative self-opinion (Bagby et al., 1986). Under this
theoretical framework, psychiatric patients with alexithymia could be
vulnerable to low self-esteem (Dentale et al., 2010), which could lead to
NSSI behaviors.
Although this hypothesis has not yet been tested in psychiatric pa­
tients, alexithymia has been found to be closely associated with low self-
esteem in general adult populations (Mousavi and Alavinezhad, 2016).
People with low self-esteem may also be prone to NSSI behaviors
because of their lack of self-regard (Forrester, 2016; Kerig, 2017). A
systematic review of clinical and non-clinical populations also found
that low self-esteem and NSSI were related (Forrester et al., 2017).
Therefore, examining the influence of a psychological mediator, such as
self-esteem, could assist in understanding the associative mechanisms
operating between alexithymia and NSSI in adult psychiatric patients.
1.3. The moderating role of emotional intelligence between alexithymia,
self-esteem, and NSSI
Emotional intelligence (EI) refers to the ability to understand, direct,
manage, control, and empathize with one’s own and others’ emotions,
discriminate those emotions, and use them to guide thinking and
behavior (Salovey and Mayer, 1990). Several studies have found a sig­
nificant link between low EI and frequent self-destructive actions, such
as NSSI and suicidal behaviors (Halicka-Masłowska et al., 2020; Kork­
maz et al., 2020; Quintana-Orts et al., 2019). In an experimental study,
EI was found to be a protective factor against suicidal behaviors, such as
suicidal ideation and suicide attempts (Cha and Nock, 2009). This EI
buffer effect, which protects individuals from engaging in NSSI and
suicidal behaviors, has been observed in many studies. For example, in a
sample of depressed adolescent inpatients, EI was found to attenuate the
effects of perceived stress on suicide risk (Abdollahi et al., 2016).
Another study also revealed that EI could be a protective factor in ad­
olescents and could assist in reducing the adverse effects of suicidal
ideation (Arrivillaga et al., 2020). A recent study also found that low EI
was positively associated with high suicidal ideation in depressive pa­
tients (Mohamed and Ahmed, 2021).
In a community sample of adults, EI was found to be strongly and
inversely related to alexithymia (Parker et al., 2001), and this link has
also been found in clinical psychiatric patient samples with panic,
generalized anxiety, and major depressive disorders (Onur et al., 2013).
Low EI has also been found to be strongly associated with
hyper-alexithymia in both general populations and psychiatric out­
patients (Fukunishi et al., 2001). EI has also been positively correlated
with self-esteem in the general population (Bibi et al., 2016; Tang et al.,
2022) and clinical samples (Khosravi and Hassani, 2022).
Therefore, it is reasonable to surmise that EI could play a protective
Z. Dong et al.
role via self-esteem in the transition from alexithymia to NSSI. However,
to the best of our knowledge, no studies have yet explored the role
played by EI in alleviating or exacerbating alexithymia and NSSI be­
haviors in psychiatric patients.
1.4. The present study
Given the above literature overview, this study sought to gain a more
comprehensive understanding of the alexithymia and NSSI mechanisms
in adult psychiatric patients. The first research aim was to explore
whether alexithymia was linked to NSSI behaviors, the second aim was
to examine whether self-esteem mediated the alexithymia and NSSI
association, and the third aim was to test whether EI moderated the path
from alexithymia to NSSI through self-esteem. These underlying alex­
ithymic and NSSI mediating and moderating mechanisms were devel­
oped to form a moderated mediation model, which is shown in Fig. 1.
Based on this model, the following hypotheses are proposed.
Hypothesis 1. Alexithymia is positively associated with NSSI in psy­
chiatric patients.
Hypothesis 2. Self-esteem mediates the relationship between alex­
ithymia and NSSI.
Hypothesis 3. EI moderates the direct and indirect relationships be­
tween alexithymia and NSSI via self-esteem.
2. Methods
2.1. Participants
From July 1, 2020, and July 20, 2021, this study recruited a
consecutive convenience sample of 449 patients at the Mental Health
Center of West China Hospital, Sichuan University, Chengdu, China, all
of whom had been diagnosed with DSM-5 non-specific mental disorders,
such as depression, anxiety, eating disorders, schizophrenia, and
obsessive-compulsive disorder (OCD). The diagnoses were performed by
trained mental health professionals such as clinical psychologists and
psychiatrists. Before giving their informed consent, all patients were
informed of the study’s purpose and their rights. All information was
confidential and anonymous, and patients were told they could with­
draw from the study at any time. This study was approved by the Ethics
Committee of Sichuan University West China Hospital ethical approval
number/ID: 2020_923). and complied with the Declaration of Helsinki.
To be admitted to the study, patients had to be at least 18 years of
age, fluent in Mandarin or Sichuan dialect, and have good reading and
writing abilities. The exclusion criteria were a family history of psy­
chosis because a family mental illness could have influenced alex­
ithymia, apparent cognitive impairment, an acute state of illness, and
comorbidities with other physical or neurological diseases. Overall,
1050 patients were asked to participate in the study, 642 patients
expressed willingness, but 193 of these were excluded (106 patients who
Fig. 1. Hypothetical moderated mediation model. Abbreviations: NSSI, Non-
suicidal self-injury.
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Journal of Psychiatric Research 162 (2023) 57–64
were under 18 years of age and 87 because of a family history of mental
illness or concomitant physical or neurological illness). Therefore,
finally, 449 people were involved in the study.
2.2. Procedures
When a patient met the criteria and was willing to participate, the
patient and their legal guardian signed the informed consent (according
to China’s Mental Health Law, mental patients have limited behavioral
responsibility during the onset period and therefore need the consent of
their legal guardians), after which the patients were invited to a quiet
room and the research assistants, who were two trained nurses or
counselors conducted face-to-face interviews. The research assistants
had Master’s degrees or above in psychology or education or clinical
medicine and had obtained their China National second-class Psycho­
logical Consultant Practicing Certificate. The patients’ basic information
was collected in the face-to-face interviews, which included screening
the participants based on the inclusion and exclusion criteria. The
standardized self-reported scales were completed by the patients with
the research assistants explaining any unclear areas. The questionnaire
answers were then coded, input into a table, and double-checked by two
graduate psychology students.
2.3. Instruments
2.3.1. Toronto Alexithymia-20 scale (TAS-20)
Alexithymia was measured using the Toronto Alexithymia-20 Scale
(TAS-20) (Bagby et al., 1994), which has 20 items that measure three
main aspects; difficulty in identifying feelings, difficulty in describing
feelings, and externally oriented thinking; each of which is rated on a
5-point scale from 1-strongly disagree to 5- strongly agree, with the total
score, which ranges from 20 to 100 points, being the sum of all items,
and with higher scores indicating more severe alexithymic symptoms. A
TAS-20 sum score threshold of ≥61 is categorized as alexithymic (Franz
et al., 2008). The Chinese version of the alexithymia scale has been
found to have good reliability and validity in both general and clinical
populations (Zhu et al., 2007) and is comparable to the English version
of the scale (Bagby et al., 1994; Parker et al., 2003). In the present study,
Cronbach’s α was 0.845.
2.3.2. Rosenberg self-esteem scale (RSES)
Self-esteem was measured using the 10-item Rosenberg self-esteem
scale (RSES) (Rosenberg, 1965), which has been widely used in
various cultures worldwide and has shown good reliability and validity
(Buhrmester et al., 2011). In the Chinese cultural context, the scale has
been found to have satisfactory reliability and validity in both psychi­
atric patients (Xu et al., 2013) and the general population (Nie et al.,
2017). Each item was rated on a 4-point scale from 1-strongly disagree
to 4- strongly agree, with the overall score being between 10 and 40, and
with high scores indicating high self-esteem. In a study involving dozens
of countries and regions with different cultural backgrounds, including
Chinese, the RSES scale had an average reliability of 0.81 (Cronbach’s
alpha) (Schmitt and Allik, 2005). In the current study, Cronbach’s α was
0.888.
2.3.3. Wong law emotional intelligence scale (WLEIS)
The 16-item Wong Law Emotional Intelligence Scale (WLEIS) (Wong
and Law, 2002), which is based on Chinese culture, was used to measure
EI. Each item is marked on a five-point Likert scale from 1 = strongly
disagree to 5 = strongly agree, with the total score ranging from 16 to
80, and high scores indicating high EI. The reliability was found to range
from 0.83 to 0.90 in Wong and Law’s (2002) research, and a comparison
of a sample of Chinese and Canadian college students found that the
Chinese and the English self-esteem scale reliabilities were comparable
(Li et al., 2012). The scale has also been found to have satisfactory
reliability and validity in Chinese psychiatric patients (Wang et al.,
Z. Dong et al. Journal of Psychiatric Research 162 (2023) 57–64

2021). The Cronbach’s α in the present study was 0.875. Table 1

Sociodemographic and clinical characteristics of the study sample (N=449)
2.3.4. DSM-5 non-suicidal self-injury (NSSI) questionnaire Variables n Prevalence (%)
The DSM-5 non-suicidal self-injury (NSSI) questionnaire asked the
Total (n=449) 100
patients to report the number of days in the previous year they had
engaged in NSSI behaviors, such as cutting/carving, hair pulling, Gender
Male 129 28.7
burning, and banging/hitting, which were rated on a 4-point Likert Female 320 71.3
scale; 1 = never, 2 = once or twice, 3 = three to five times, and four = six Age (yrs.)
times or more; with the total score being the sum of the item scores, and 18-35 344 76.6
with high scores indicating severe NSSI behavior. Regardless of the NSSI 36-50 75 16.7
51-73 30 6.7
type, incidents >5 days in the previous year were considered indicative
Education
of an NSSI disorder (Edition, 2013; Muehlenkamp et al., 2017). This Junior high school or below 60 13.3
questionnaire has proven reliable and valid in Chinese populations (You Senior high school 140 31.2
et al., 2013, 2015). The Cronbach’s α in the present study was 0.910. College degree or above 249 55.5
Residence
Rural 177 39.4
2.4. Statistical analyses Urban 272 60.6
Marital status
Descriptive statistics were used to calculate the sociodemographic Single 264 58.7
variable percentages, the relevant clinically variable proportions, and Married 160 35.7
Divorced 25 5.6
the NSSI disorder forms and category ratios. The means, SDs, and
Only child status
bivariate Pearson’s correlations for the main variables were calculated Yes 210 46.8
using SPSS 22. An independent-sample t-test was used to compare the No 239 53.2
NSSI frequencies for the alexithymic and non-alexithymic patients, and Family Income(per month)
the SPSS PROCESS macro Model 4 was employed to test the mediation ＜5000 ¥ 206 45.9
5000-10000 ¥ 122 27.2
and the moderated mediation models by calculating the 95% confident ＞10000 ¥ 121 26.9
intervals (CI) based on a 5000 bootstrap resampling (Hayes, 2017). DSM-V NSSI Disorder
Multiple nominal logistic regressions were used to explore the inde­ Yes 146 32.5
pendent associations and adjusted odds ratios (ORs) between the NSSI No 303 67.5
Alexithymic
and sociodemographic variables; age, gender, education level, rural or
Yes 203 45.2
urban, marital status, only-child status, and family income; the clinical No 246 54.8
variables (mental illness), and those with alexithymia. Mental illness
Depression only 77 17.1
3. Results Anxiety only 88 19.6
Depression comorbid anxiety 168 37.4
Bipolar disorder 48 10.7
As shown in Table 1, the sample was aged between 18 and 73 years, Obsessive-compulsive disorder (OCD) 30 6.7
with a mean age of 28.59 (SD = 11.63). The DSM-V NSSI Disorder (>5 Schizophrenia 18 4.0
days in the past year) prevalence was 32.5% (n = 146) and alexithymic Schizoaffective disorder 12 2.7
Anorexia nervosa 8 1.8
prevalence (TAS total score≥ 61) was 45.2% (n = 203).
The NSSI disorders and categories were: excessive friction causing Abbreviations: NSSI= non-suicidal self-injury; ¥- Chinese yuan or Renminbi
bleeding (n = 91, 62.3%), scratching or pinching the skin (n = 82,
56.2%), cutting or stabbing the skin (n = 80, 54.8%), pulling hair (n =
76, 52.1%), punching self (n = 75, 51.4%), biting self (n = 72, 49.3%), Table 2
banging head (n = 58, 39.7%) and burning self (n = 5, 3.4%). Descriptive statistics and correlations for the main study variables (N=449)
Means, standard deviations, and correlations for the main study Variable Mean SD 1 2 3 4
variables are given in Table 2. Alexithymia was found to be positively 1. Alexithymia 59.38 11.49 1
correlated with NSSI (r = 0.41, p < 0.01) and negatively correlated with 2. NSSI 5.66 6.78 0.41** 1
self-esteem (r = − 0.57, p < 0.01) and EI (r = 0.54, p < 0.01). 3. Self-esteem 22.70 6.23 -0.57** -0.55** 1
4. Emotional intelligence 66.35 15.57 -0.54** -0.47** 0.60** 1
The results of the moderated mediation model are shown in Fig. 2.
When self-esteem was controlled for, the mediation model revealed a **p < 0.01
significant association between alexithymia and NSSI (Table 3). The Abbreviations: NSSI=non-suicidal self-injury; SD=standard deviation
bias-corrected percentile bootstrap method indicated that the indirect
effect of alexithymia on NSSI through self-esteem was significant; b = 4. Discussion
0.26, SE = 0.03, 95% CI = [0.19, 0.30]; with the mediation effect ac­
counting for 59% of the total effect. EI, however, was only found to Alexithymia is a common state in psychiatric patients and is usually
moderate the direct association between alexithymia and NSSI (Table 4 correlated with adverse behavioral and psychological problems (Hébert
and Fig. 3); b = − 0.18, SE = 0.05, 95% CI = [− 0.26, − 0.09]. et al., 2018; Sfeir et al., 2020; Tang et al., 2020), with NSSI being one of
The results of the multivariate nominal logistic regression are shown the more negative consequences (Greene et al., 2020; Norman et al.,
in Table 5. Alexithymic patients had higher odds of engaging in NSSI 2020). Therefore, identifying the mechanisms underlying alexithymia
than non-alexithymic patients (OR 2.76). Compared with patients with and NSSI behavior is essential to developing protective prevention and
depression and except for patients with anxiety, who had a significantly intervention initiatives. By examining the possible mediating role of
lower risk (OR = 0.34), patients with other mental disorders had a self-esteem and the moderating role of EI, this study expanded on pre­
similar risk of NSSI. If the patients over 50 years old were taken as a vious studies by exploring the associations between alexithymia and
reference, the other ages, 18–35 years old and 36–50 years old, both NSSI. To the best of our knowledge, this was the first study to examine
showed higher NSSI risks, with respective ORs of 2.95 and 3.61. the underlying psychological mechanisms between alexithymia and
NSSI behavior in psychiatric patients. It was found that 68.4% of the

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Z. Dong et al. Journal of Psychiatric Research 162 (2023) 57–64

should be prioritized for programs that heighten their perception and

recognition of their emotions.
Similar to previous research (Honkalampi et al., 1999; Kumar et al.,
2018; Saarijärvi et al., 1993), this study found that around 45.2% of the
study’s patients had serious alexithymia (scores greater than 61 in the
TAS-20), that is, nearly half had difficulties identifying and expressing
their feelings, which was significantly higher than the 10% found in
general German and Finnish populations (Franz et al., 2008; Honka­
lampi et al., 2000). This high comorbidity between mental illness and
severe alexithymia, therefore, could be related to poor emotional
regulation abilities (Pace et al., 2022; Pandey et al., 2011; Preece et al.,
2022); however, further studies are needed to confirm this association. It
Fig. 2. Moderated mediation models. was also found that patients under 50 years old were more likely to
***p < 0.001. engage in NSSI behavior; however, further research is needed as the
Abbreviations: NSSI = non-suicidal self-injury. number of patients over 50 years old was small in the sample.
To the best of our knowledge, this study is one of few studies to find
that self-esteem mediated alexithymia and NSSI, which provides some
Table 3 guidance for the development of effective NSSI intervention programs
Mediation effects of alexithymia on NSSI (N=449) for psychiatric patients that raise self-esteem or reduce alexithymia.
Predictors Model 1(NSSI) Model 2(SE) Model 3(NSSI) These results were also partly in line with an experimental study that
β t β t β t
found that cognitive interventions aimed at improving self-worth in
people with NSSI behavior effectively reduced their pain endurance
Alexithymia 0.41 9.23*** -0.57 -14.19*** 0.17 3.36**
(Hooley & St. Germain, 2014). In line with the findings of the current
SE -0.43 8.55***
R2 0.17 0.32 0.29 study, previous research has also suggested that self-esteem mediates
F 85.18*** 201.35*** 86.38*** other risk factors and NSSI behaviors. For example, in a college student
**p < 0.01; ***p < 0.001.
sample, low self-esteem was found to mediate the relationship between
Abbreviations: NSSI=Non-self-injurious suicidal behavior; SE=self-esteem

study patients had engaged in at least one type of NSSI behavior in the
previous twelve months, and people with different types of mental dis­
orders had similar risks. As surmised, with an OR of 2.76, the alex­
ithymic patients were more independently associated with NSSI than the
non-alexithymic patients. While self-esteem was found to partly mediate
the relationship between alexithymia and NSSI, EI was only found to
moderate the path from alexithymia to NSSI. Patients who reported high
alexithymia and low EI were also more likely to have engaged in NSSI
behavior.
As expected, alexithymia was directly related to NSSI, and the
alexithymic patients were about 2.76 times more likely to exhibit NSSI
behavior than the non-alexithymic patients. The results of this study
confirmed earlier studies on adolescent psychiatric patients (Lüdtke
et al., 2016) and on general populations (Norman et al., 2021). As found
in previous studies (Sleuwaegen et al., 2017), the alexithymic patients
reported higher NSSI rates than the non-alexithymic patients, which
indicated that alexithymics have a significantly higher risk of engaging
in NSSI. Therefore, this study provides additional evidence that psy­
chiatric patients with severe alexithymia comorbidities are NSSI risks.
The NSSI cognitive-emotional model (Hasking et al., 2017) indicates
that as alexithymics are less able to regulate their emotions, there is a Fig. 3. The EI moderation effect between alexithymia and NSSI. High and low
possible link to NSSI (McKenzie and Gross, 2014). Therefore, when EI represents one standard deviation above and below the mean. Abbreviations:
seeking to reduce NSSI behaviors in psychiatric patients, alexithymics EI, emotional intelligence; NSSI, non-suicidal self-injury.

Table 4
Moderated mediation effect of alexithymia on NSSI (N=449)
Predictors Model 1(NSSI) Model 2(SE) Model 3(NSSI)

β se t %95CI β se t %95CI β se t %95CI

Alexithymia 0.31 0.050 6.17*** 0.21~0.41 -0.36 0.049 -7.56*** -0.46~-0.27 0.20 0.052 3.77*** 0.09~0.30
EI -0.28 0.045 -6.22*** -0.37~-0.19 0.37 0.043 8.68*** 0.29~0.46 -0.15 0.046 -3.34*** -0.25~-0.06
Alexithymia*EI -0.15 0.035 -4.45*** -0.22~-0.09 -0.01 0.033 -0.26 -0.08~0.06 -0.18 0.046 -3.83*** -0.26~-0.09
SE -0.32 0.050 -6.39*** -0.42~-0.22
SE*EI -0.03 0.046 -0.59 -0.12~0.06
R2 0.28 0.43 0.35
F 53.27*** 103.94*** 44.66***

***p < 0.001; **p < 0.01.

Abbreviations: Abbreviations: EI=Emotional intelligence; SE=self-esteem; NSSI=Non-self-injurious suicidal behavior

61
Z. Dong et al. Journal of Psychiatric Research 162 (2023) 57–64

Table 5 NSSI should also seek to improve EI to allow patients to better identify
Independent variables associated with NSSI based on the multinomial logistic and manage their emotions, perceive, understand, and judge the feelings
regression (N=449) of others, and improve their communication skills.
NSSI In sum, this study increases the understanding of the effects of
Variables OR (95%CI)
alexithymia on NSSI behavior in adult psychiatric patients and the
relationship variations under different EI levels. However, there were
Gender
several study limitations. First, this study time ordered the variables
Female 1.00
Male 0.82(0.50-1.33) retrospectively, which is no substitute for collecting data at different
Age (yrs.) time points (i.e., longitudinally). Second, the sample was not large
51-73 1.00 enough for representative purposes and the mental illness distribution
18-35 2.95(1.08-8.03) * was uneven, which impacted any generalization of the conclusions.
36-50 3.61(1.33-9.78) *
Education
Third, in retrospective studies, participants may have memory biases
College degree or above 1.00 (Roy et al., 2005), especially for their experiences in the previous few
Junior high school or below 1.46(0.69-3.08) years. Fourth, the sample was unbalanced toward females and younger
Senior high school 1.81(1.04-3.15) * participants, which could have affected the outcomes because the
Residence
alexithymic distribution was used to show the gender differences (Muzi,
Rural 1.00
Urban 0.68(0.40-1.15) 2020); therefore, this needs to be considered in future research. Fifth,
Marital status some other psychological and personality variables, such as neurotic or
Divorced 1.00 psychopathic personalities, that might play a role in NSSI behaviors and
Single 2.15(0.81-5.68) patient treatment were not investigated. Therefore, longitudinal designs
Married 1.28(0.51-3.24)
Only child status
and objective indicators could better confirm the psychosocial mecha­
Yes 1.00 nisms associated with NSSI.
No 0.97(0.60-1.57) Despite these limitations, the study findings offer insights into the
Family Income(per month) NSSI mechanism and possible prevention programs for psychiatric pa­
1.00
＞10000 ¥
tients. First, the high NSSI rate in the psychiatric sample warrants
＜5000 ¥ 0.64(0.36-1.13)
5000-10000 ¥ 0.75(0.41-1.39) attention as this prevalence can severely affect the quality of life and
Alexithymic patient safety. Second, as the NSSI prevalence in the alexithymics was
Yes 1.00 extremely high, alexithymia should be recognized as a significant risk
No 2.76(1.72-4.42) *** factor when screening for NSSI. Third, psychological NSSI interventions
Mental illness
Depression only 1.00
in mentally ill populations should focus more on nurturing emotional
Anxiety only 0.34(0.16-0.67) ** recognition and expression abilities, increasing patient self-esteem and
Depression comorbid anxiety 0.97(0.49-1.91) self-worth, and developing their interpersonal skills to improve their
Bipolar disorder 0.79(0.31-1.97) abilities to understand their own and other people’s emotions and be
Obsessive-compulsive disorder (OCD) 0.43(0.16-1.11)
able to judge and react better to their emotions, all of which could
Schizophrenia 1.04(0.28-3.81)
Schizoaffective disorder 1.23(0.19-7.83) reduce their NSSI risk.
Anorexia nervosa 0.33(0.09-1.23)
Declaration of conflicting interests
***p < 0.001; **p < 0.01;*p < 0.05
Abbreviations: NSSI= non-suicidal self-injury; ¥=Chinese yuan or Renminbi
The authors declare no potential conflicts of interest concerning the
research, authorship, and/or publication of this article.
poor early attachment and self-injury (Harrison, 2009). Another study
conducted on college students found that self-esteem fully mediated the
Ethical approval
relationship between personality disorders and NSSI (Cawood and
Huprich, 2011), and in an eating disorder study, self-esteem was found
All procedures performed in the present study were in accordance
to mediate childhood abuse and NSSI (Whitlock et al., 2011). A possible
with the ethical standards of the 1964 Helsinki declaration and its later
explanation is that alexithymics are more likely to experience a sense of
amendments. This study was approved by the Ethics Committee of
shame (Franzoni et al., 2013) and self-dissatisfaction (De Berardis et al.,
Sichuan University West China Hospital (2020_923).
2009), that is, there may be a causal connection between alexithymia
and self-depreciation (Bagby et al., 1988), which in turn aggravates low
Informed consent
self-esteem and the risk of NSSI behavior (Forrester et al., 2017). This
study provides a new explanation for the NSSI psychological mechanism
Informed consent was obtained from all participants and their
in psychiatric patients and provides a direction for future interventions.
guardians.
However, as the cross-sectional design impeded a definitive confirma­
tion of this directionality, future longitudinal research designs are
CRediT authorship contribution statement
needed.
Another important finding was that EI played a protective role in the
Zaiquan Dong: and. Jing Zhou: analyzed the data and. Aldo Conti:
relationship between alexithymia and NSSI. Even if patients have hyper-
and. Samuel J. Westwood: prepared the Tables and Figures and revised
alexithymia, those with high EI would have a lower NSSI risk. Previous
the manuscript. Xia Fu: and. Qi Liu: and. Yanling Yuan: participated in
research has also found EI to be an important protective factor against
data collection and provided support for the study design. All authors
suicidal behavior (Cha and Nock, 2009; Domínguez-García and
read and approved the final manuscript. Xia Huang: and. Changjian
Fernández-Berrocal, 2018). Although EI and alexithymia are strongly
Qiu: and. Xiaohui Zhang: designed the protocol for the study, managed
and inversely related, EI is independent of alexithymia (Parker et al.,
and analyzed the data, wrote, and revised the manuscript. Wanjie Tang:
2001). EI involves recognizing one’s own emotions, being able to read
and, draft manuscript.
the moods, intentions, and desires of others, and having the adaptive
capacities and skills to control impulses and cope with stress (Bar-On,
2006). Therefore, intervention programs for psychiatric patients with

62
Z. Dong et al.
Acknowledgments
The authors thank all participating patients, their families，and
research collaborators.
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