Characteristics of non-suicidal self-injury in women accessing internet help sites

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1 Clinical Psychologist 22 (2018) Characteristics of non-suicidal self-injury in women accessing internet help sites Emma B. Black 1,2 and Helen Mildred 1 1 School of Psychology, Deakin University, Burwood, Victoria and 2 School of Medicine, University of Queensland, Rural Clinical School, Darling Heights, Queensland, Australia Key words deliberate self-harm, non-suicidal self-injury, self-harm, self-injurious behaviour, self-injury. Correspondence Emma Black, School of Medicine, Rural Clinical School, University of Queensland, PO Box 496, Darling Heights, QLD 4350 Australia. e.black@uq.edu.au Received 25 May 2015; accepted 19 March doi: /cp Abstract Background: This article aimed to examine and compare the frequency of occurrence of a broad range of non-suicidal self-injury (NSSI) behaviours in an international sample of women. Methods: Female participants with NSSI (n = 464) were recruited via a range of websites and completed a questionnaire examining 17 different types of NSSI and their frequency, severity, and duration. Results: Prevalent acts were cutting, scratching, and word carving; cutting and scratching occurred frequently, whilst word carving most often occurred as a single episode. Analyses revealed significant differences between Australian and U.S. participants, with U.S. participants having significantly higher rates of cutting, wound interference, carving, scratching, and sharp object sticking. Participants also reported on other self-harm methods not assessed by the questionnaire. Conclusions: Word carving may be qualitatively different from other forms of NSSI. More severe NSSI methods (e.g., bone breaking) are less prevalent than less dangerous methods (e.g., scratching). Participants considered a range of indirectly harmful or suicidal behaviours as self-injury contrary to researcher or clinician understanding. Finally, there may be cultural differences in relation to NSSI between countries where such behaviours are common, although further research is required to determine this. Key Points 1 Word carving may be qualitatively different from other forms of non-suicidal self-injury (NSSI). 2 Participants considered other harmful behaviours as self-injury contrary to researcher definitions 3 Some NSSI methods were significantly higher for U.S. than Australian participants Non-suicidal self-injury (NSSI) has been defined as deliberately inflicting minor to moderate damage to the Funding: None. Conflict of interest: None. body (without suicidal intent) in a manner that is not culturally accepted (e.g., American Psychiatric Association, 2013). Common behaviours include cutting and scratching oneself (Martin, Swannell, Hazell, Harrison, & Taylor, 2010; Swannell, Martin, Page, Hasking, & St John, 2014). In Australia, lifetime prevalence of this behaviour in a large, random community sample (N = 12,006) has been identified at 8.1%, with one month prevalence at 1.1% (Martin et al., 2010). In the United States, a stratified community sample found sixmonth prevalence was 4% (N = 927; Briere & Gil, 1998), whilst more recent research has found lower community rates (0.9% for 12-month prevalence and 5.9% for lifetime prevalence; Klonsky, 2011). Whilst overall NSSI prevalence differs between countries, research has also found that prevalence of individual NSSI methods also varies significantly, particularly 2016 The Australian Psychological Society 37

2 Black and Mildred rates of cutting and overdose (Madge et al., 2008); overdose, however, is not typically considered NSSI. Prior studies have incidentally outlined the occurrence of a broad variety of NSSI methods (Brown, Williams, & Collins, 2007; Saraff & Pepper, 2014), rather than just reporting overall prevalence or on only a few methods. These studies, however, have both been limited by utilising small samples of college students (n = 55 for Brown et al. (2007), and N = 52 for Saraff & Pepper (2014)) and reporting method prevalence only. The literature reports mixed findings regarding whether there are gender differences for NSSI. A recent meta-analysis of 116 papers, however, identified that females were more likely to engage in NSSI (Bresin & Schoenleber, 2015) and that this was more pronounced in clinical samples. Other research with adolescents has also identified gender differences in NSSI methods, with females being more likely to use cutting, scratching, or carving than males (Barrocas, Hankin, Young, & Abela, 2012; Sornberger, Heath, Toste, & McLouth, 2012). As it appears there is a gender bias, the current research is focused on exploring NSSI in females. Some research into self-injury has been internet-based (Andover, 2014; Gollust, Eisenberg, & Golberstein, 2008; Whitlock, Powers, & Eckenrode, 2006), which allows access to large samples. Andover s study recruited a community sample of American adults (N = 548) through a job-seeking forum, finding that 23% of participants endorsed NSSI (lifetime prevalence). Evidence also exists that data collection via computer may increase disclosure on sensitive topics (Kim, Dubowitz, Hudson-Martin, & Lane, 2008; Turner et al., 2009). NSSI is a sensitive topic, with one study finding that 57% of people had never disclosed their self-injury to others (Armiento, Hamza, & Willoughby, 2014); for people who had disclosed, only 26% had disclosed to formal sources (such as professionals). Furthermore, young people with self-injury are more likely than their peers to have high internet usage (Mitchell & Ybarra, 2007). In summary, therefore, it seems that females are generally more likely than males to engage in NSSI as well as utilise certain methods. Reported rates of individual NSSI methods also reportedly vary between countries. The current study, therefore, examined a broad variety of NSSI methods within a large, international sample of females. Aims The objective of this article is to detail findings regarding the occurrence of a wide variety of NSSI behaviours in an international web-based sample of females. In addition to this, comparisons of NSSI methods are made between two developed nations (Australia and the USA), which have not previously been reported. Data are drawn from a larger study (Black & Mildred, 2014) for this purpose. Method Participants This study aimed to recruit females aged 18 years and older; 626 participants responded. Following data cleaning, the sample consisted of 574 females. Participants were aged years (M = 26.4 years); country of residence is reported in Table 1. Materials A demographics section and the Deliberate Self-Harm Inventory (DSHI; Gratz, 2001) were employed. The DSHI measures whether someone has deliberately selfinjured without intending to kill themselves across 17 dichotomous items (scoring 1 if the respondent has ever used that form of NSSI and 0 if not). Each item has sub-items to identify behaviour frequency, duration, and severity. Research on the DSHI has indicated that it has sound reliability and validity (Gratz, 2001; Gratz & Chapman, 2007). In the current study, Cronbach s α =.81. Procedure Recruitment was web-based, with study information placed on a variety of national and international websites dedicated to mental health, eating disorders, depression, self-injury, and psychological research. Participants Table 1 Country of residence reported by participants Country of residence n Percent of sample (%) Australia United States of America United Kingdom Canada New Zealand Netherlands Austria Other European countries a Middle Eastern countries b Asian countries c Other d Not reported 23 4 a Germany, Sweden, Norway. b Israel, Lebanon. c Singapore, Pakistan, Turkey. d Barbados, Paraguay, South Africa The Australian Psychological Society

3 NSSI characteristics self-referred to the study by following the weblink to the survey to view a plain language statement. If participants confirmed that: (1) they had read this statement and agreed to participate, and (2) they were over 18 years of age, then the survey page loaded. People received no compensation for participation. The research was approved by Deakin University s Human Research Ethics Committee. Data Preparation Fifty-two cases were excluded due to: male gender (n = 23); under 18 years (n = 2); not disclosing age or gender (n = 1); duplicate responses (n = 1); inappropriate responses (e.g., repeatedly writing their name in free response sections; n = 2); and substantial missing data (n = 23). Missing data involved no responses at all on the DSHI (n = 8) or not completing a whole inventory elsewhere in the larger dataset (n = 15; Black & Mildred, 2014). Results Number of Methods Of the 574 cases, 80.8% (n = 464) reported engaging in at least one type of NSSI at some point in their lives. Only data from the 464 participants who endorsed NSSI are therefore reported in this study. Most participants with NSSI reported multiple methods (87.4%), with a range of one to 13+ NSSIs endorsed (M = 4.02; Mode = 5; SD = 3.30). Specifically, 13% used only one method, 13% had used two methods, and 9% had engaged in three methods (details in Table 2). NSSI typically initiated in adolescence across methods (Table 3). Table 2 Participants with non-suicidal self-injury: Number of methods reported Method Prevalence The most common acts reported were cutting, scratching, and carving words into one s skin (Table 3). In relation to cutting and scratching, some participants (n = 65 and n = 43, respectively) did not specify the number of times they had engaged in the behaviour, instead providing estimates in the 100 s, 1000s, or responses such as I don t know or too many too mention. As a result, mode was used (Table 3) as the measure of central tendency most likely to provide insight into the behaviours. This measure indicated that the most common frequency reported for cutting and scratching was 100, whereas it was one episode for carving words. The second most commonly reported frequency for carving words was two episodes (n = 34, 5.9%), and only a small number of estimates was provided, for example, Approx 15 or 10+. Therefore, whilst word carving was a prevalent act, it did not typically appear to be part of a repetitive pattern for most participants (unlike cutting and scratching). Some other behaviours also had very low modes (i.e., 1 or 2), including: burning with a cigarette; carving designs; sandpapering; acid dripping; bone breaking; and head banging. These behaviours were, however, less prevalent than word carving (which 35.2% of participants endorsed), ranging from 2.6% (acid dripping) up to 22.6% (head banging). Types of self-injury most commonly reported to require medical attention (Table 4) were bone breaking, cutting, and other. The other item captured behaviours not measured by prior DSHI items and was prevalent (31.5%, n = 181; see Table 4 for other methods disclosed). This item largely captured highly specific behaviours (e.g., scraping skin off or closing body parts inside doors), although a range of behaviours not considered NSSI were also reported (e.g., suicide attempts and overdoses, which may explain the increased medical intervention required for this item). Number of methods used n (% of sample) 1 59 (12.7) 2 62 (13.4) 3 43 (9.3) 4 56 (12.1) 5 64 (13.8) 6 44 (9.5) 7 40 (8.6) 8 35 (7.5) 9 22 (4.7) (3.9) (2.2) 12 6 (1.3) (1.1) Comparison by Country Participants were predominantly from Australia (n = 222) and the United States (n = 206), with the groups having similar mean ages (USA M = 26.3 years; Australia M = 27.7 years). Statistical analysis revealed that the U.S. sample had significantly higher lifetime prevalence of cutting, carving (both words and other designs), scratching, sharp object sticking, and preventing wounds healing (Table 5). Head banging was the only behaviour more prevalent in the Australian sample, and this was not significant The Australian Psychological Society 39

4 Black and Mildred Table 3 Descriptive statistics for the range of non-suicidal self-injury methods NSSI type Lifetime prevalence n (%) Medical attention required n (%) Age of onset range: min max Age of onset: mean Age of onset: mode Frequency range: min max Frequency mode a Cutting 386 (67.2) 162 (42.0) ,000, Burning 97 (16.9) 12 (12.4) ,000 1; 2 cigarette Burning lighter/ 136 (23.7) 13 (9.6) match Carving words 202 (35.2) 18 (8.9) ,000 1 Carving designs/ 128 (22.3) 25 (19.5) other Severe 277 (48.3) 40 (14.5) , scratching Biting 95 (16.6) 3 (3.3) /s 5 Sandpapering 22 (3.8) 1 (4.5) ; 15; Acid dripping 15 (2.6) 4 (26.7) Chemical 23 (4.0) 3 (13.0) scrubbing Sharp object 179 (31.2) 16 (8.9) , sticking Glass rubbing 63 (11.0) 13 (20.7) Bone breaking 17 (3.0) 13 (76.5) Head banging 130 (22.6) 18 (13.9) ; ; 2 Punching 167 (29.1) 12 (7.2) ,000,000 5 Preventing 188 (32.8) 5 (2.7) , wound healing Other b 181 (31.5) 73 (40.3) ; 16 NSSI, non-suicidal self-injury. a Mean is not reported as many participants provided estimates or non-numerical reports of NSSI frequency. Therefore, Mode is used here as the measure of central tendency most likely to be reliable. b Other methods reported in Table 4. Discussion General Findings Findings were consistent with prior research that NSSI typically initiates in adolescence; the most prevalent behaviours were cutting and scratching; and that the use of multiple NSSI methods is common (Klonsky, 2011; Martin et al., 2010). It must, however, be noted that figures regarding number of methods used is high in the current study (87.4% of participants reported multiple methods, and some had engaged in as many as 13) as compared to community-based samples such as Klonsky (2011) and Martin et al. (2010) s studies. This will likely be due to differing samples and recruitment strategies. The current prevalence rates for NSSI are also higher than in other online NSSI research (Andover, 2014), indicating that the targeted recruitment strategy was effective. Frequency NSSI frequencies varied widely between participants, and some participants provided estimates or statements that they did not know the number of times they had engaged in an act. Retrospective information will make it more challenging to quantify exact frequencies, particularly when NSSI is a repetitive pattern (rather than an occasional act). This finding differs from prior research, which has found lower rates of repetitive NSSI (Zetterqvist, Lundh, Dahlstrom, & Goran Svedin, 2013). Prior research has considered NSSI severity in terms of frequency, lethality, and number of methods (Andrews, Martin, Hasking, & Page, 2013). One study also found that number of NSSI methods, combined with NSSI frequency, was significantly related to number of suicide attempts (Anestis, Khazem, & Law, 2015). Assessing the number of NSSI methods present may therefore be an The Australian Psychological Society

5 NSSI characteristics Table 4 Other types of self-injury reported by participants Method n Suicide attempts a 42 Burning self with other instruments b 35 Disordered eating behaviours c 19 Destructive behaviours not resulting in immediate tissue damage d 12 Ingesting potentially hazardous material e 9 Punching a wall or things 7 Overdoses specified as intentionally non-fatal or mini-overdosing 6 Pinching, banging, or squeezing skin until it bruises 5 Slapping or hitting oneself 5 Hitting oneself with blunt object (e.g., hammer, spanner) 4 Swallowing sharp objects (e.g., razorblades, tacks) 3 Inserting objects into one s vagina (e.g., razorblades, too many tampons) 3 Snapping rubber band against skin to break it or cause welts 3 Biting gums or lips until swollen/bleeding 3 Closing body parts inside doors 3 Slamming/banging hands or wrists on hard surfaces, causing bruising 3 Acts subthreshold to DSHI items f 3 Items already on the DSHI g 3 Scraping skin off (with a razor; against rough surfaces) 3 Piercing or tattooing self 2 Whipping oneself (e.g., with a chord) 2 Giving oneself frostbite intentionally 2 Banging knee or elbow against hard surfaces (one reported to be pulverised as a result) 2 Choking or strangling oneself 2 Jumped off a bridge or building 2 Provoking an animal (cat, dog) to bite or attack 2 Provoking fights 2 Removing chunks of flesh or skin 2 Other h 17 a Reports included: tried to commit suicide with cut wrists and overdosing on paracetamol, aspirin, drugs, medication, mixing alcohol and medication, and/or diet pills. b Instruments reported included: boiling water; hot wax; canned air duster; iron; hair straightener; curling iron; stove; oven; ice and salt; eraser; carpet or rug; rolled burning paper; heated metal object; caustic soda; electric range; heated coffee mug; light globes; incense; and fire. c Behaviours reported included: starving oneself or not eating, gorging or eating uncontrollably, purging, vomiting, bulimia, and eating disorder. d Excessive laxative use to cause pain, exercising until lose consciousness, promiscuity, addictions, not taking insulin, avoided drinking water for days, eating the wrong foods, overheated oneself. e Reports included consuming: Poison or chemicals (for example, bleach), food or medication that one is allergic to, eating food that one believes will result in food poisoning or will make oneself sick. f Head banging without bruising; attempting to break bones. g Cutting self; putting stones or ash in wounds (preventing wounds healing). h Sucking a toilet aerosol can; tying cords tightly around limbs; grinding fists, knuckles, or knees into walls; pushing a stiletto into chest, causing bruising; pushing fingers into eyes; tasering oneself; beating self with nails in a carpet tack; running on injuries until crutches required; digging nails into skin; puncturing veins with sharp objects ; hitting knuckles against other fist; twisting ankles to try and sprain them; kneeing self in face; Using tools (dremel, scalpel) to remove tattoos; inserting objects between teeth; cut my throat; and, stabbing self with a glass shard. DSHI, Deliberate Self-Harm Inventory. important part of assessing risk and severity, particularly when frequency reports may not be reliable. Low Prevalence Behaviours The least prevalent NSSI methods (acid dripping, bone breaking, chemical scrubbing, sand papering, and glass rubbing) have the potential to cause greater pain and/or harm than more prevalent methods (such as cutting or scratching). They may also be less prevalent due to requiring specific equipment that may not be readily available (e.g., acid, sandpaper, chemicals, or heavy blunt objects). These behaviours may also reflect a higher level of aggression: Kleiman et al. (2015) found that trait aggression differentiated more aggressive NSSI from less aggressive NSSI. Kleiman et al. (2015), however, categorised more aggressive NSSI as self-punching and head banging; the low prevalence NSSI methods in the 2016 The Australian Psychological Society 41

6 Black and Mildred Table 5 Differences in lifetime prevalence of non-suicidal self-injury for Australian and American participants NSSI method Lifetime prevalence: Australia a n (%) Lifetime prevalence: USA b n (%) Pearson s χ 2c,d Cutting 125 (56.3) 157 (76.2) *** Burning cigarette 33 (14.9) 42 (20.4) Burning lighter/match 51 (23.0) 58 (28.2) Carving words 62 (27.9) 87 (42.2) 9.635* Carving designs/other 42 (18.9) 57 (27.7) 4.602* Severe scratching 86 (38.7) 111 (53.9) 9.865* Biting 33 (14.9) 36 (17.5) Sandpapering 6 (2.7) 7 (3.4) Acid dripping 5 (2.3) 7 (3.4) Chemical scrubbing 8 (3.6) 9 (4.4) Sharp object sticking 57 (25.7) 74 (35.9) 5.282* Glass rubbing 25 (11.2) 23 (11.2) Bone breaking 5 (2.3) 8 (3.9) Head banging 52 (23.4) 37 (18.0) Punching 62 (27.9) 60 (29.1) Preventing wound healing 53 (23.9) 83 (40.3) *** Other 65 (29.3) 66 (32.0) ***p <.001; **p <.01; *p <.05. a n = 220. b n = 206. c With 1 degree of freedom. d No cells had an expected count less than five. NSSI, non-suicidal self-injury. current study are more damaging than punching or head banging. Other research has also found that self-criticism, suicide proneness, and a greater number of past suicide attempts differentiated people with indirect self-harm from people with NSSI (St. Germain & Hooley, 2012). These variables may also differentiate people with more severe NSSI (such as bone breaking) from those with less severe NSSI (such as scratching). Future research utilising qualitative, in-depth interviews with people who have engaged in both more harmful and less harmful behaviours may identify themes and features that differentiate choice of NSSI method(s). Word Carving Word carving, a common method, differed from other common NSSI methods in that it is more likely to occur only once. Prior research in a sample of adolescents (with a suicide attempt) found that word carving was the most common NSSI reported and typically with low frequency (Guertin, Lloyd-Richardson, Spirito, Donaldson, & Boergers, 2001). Number of episodes endorsed by participants were 1 episode (14% of sample), 2 5 episodes (14%), 6 10 episodes (4%), and 10+ episodes (1%). The current findings are therefore consistent with prior research. Word carving may have another purpose beyond typical NSSI functions; it may potentially involve an aesthetic or symbolic component. One study described skin carving amongst a sample of female adolescents (Schwartz, Cohen, Hoffman, & Meeks, 1989), which included etching boyfriends initials (44%); the Christian cross (32%); symbols such as satanic, swastikas, and peace signs (31%); and music group symbols (15%). The carvings were described as typically 1-inch long, although 34% of participants had larger scars. Schwartz et al. (1989) s findings indicate that carving may well have a meaningful or aesthetic purpose. Other research has found that culturally accepted practices such as tattooing and piercing tend to be done for aesthetic reasons, whereas NSSI is often used for affective modulation and/or other psychological reasons (Aizenman & Conover Jensen, 2007; Claes, Vandereycken, & Vertommen, 2005); Aizenman and Conover Jensen (2007) found that motivations were significantly different between practices. Word carving may potentially have a similar function to behaviours such as tattooing or piercing. Further research is required to determine the function of this behaviour and whether it is qualitatively different from other forms of NSSI. If this were to be the case, then word carving may be reconceptualised as an aesthetic practice rather than as self-injury. Other Self-Injury The final DSHI item assessed whether participants engaged in acts not measured by prior items. Responses The Australian Psychological Society

7 NSSI characteristics to this item included a broad range of acts, and not all of these were consistent with the NSSI construct. For example, acts that are considered self-damaging (but not actually self-injuring), risky, or suicidal were reported by participants (such as disordered eating, overdoses, substance addictions, purposeful dehydration, jumping from a height, or provoking fights). Straiton, Roenb, Dieserudc, and Hjelmelandd (2013) also found that participants reports regarding self-injury method were not consistent with researcher definition and highlight that this incongruence may result in some types of self-harm being overlooked. Another study found an overlap between people with NSSI and indirect self-harm, with increased impulsivity, negative affect, aggression, dissociation, disinhibition, borderline personality traits, and lower self-esteem (St. Germain & Hooley, 2012). What differentiated these two groups, however, were levels of self-criticism and suicide attempts. Given the discrepancy between participant and researcher definition of NSSI, this highlights the need for a comprehensive assessment when working with people who self-injure. Comparison by Country Analyses revealed that U.S. participants reported significantly higher rates of cutting, carving words, carving other designs, scratching, sharp object sticking, and preventing wound healing than Australian participants (Table 5). Prior international research with representative adolescent samples has found cultural differences in NSSI methods (Madge et al., 2008), although one method was not NSSI (overdosing), and the United States was not included in their sample. Therefore, there may be some cultural differences in NSSI between Australia and the United States, although further research is required to determine this. Limitations The current web-based study was biased towards recruiting participants with NSSI due to the self-injury, mental health, and research websites that they were recruited from. As a result, a large number of participants had engaged in frequent and varied NSSI, and the sample is not representative of general or clinical populations. Findings may, however, be clinically relevant given evidence that young people with NSSI have higher internet usage than their peers (Mitchell & Ybarra, 2007); in one year, more than 42 million internet searches regarding self-injury were made (Lewis, Mahdy, Michal, & Arbuthnott, 2014); and that recent research has suggested the importance of clinicians assessing internet usage in those with NSSI (Lewis, Heath, Michall, & Duggan, 2012; Lewis & Seko, 2015) due to the potential for harm and benefit. Summary and Conclusions Key findings include: U.S. participants endorsed several NSSI methods significantly more often than Australian participants; word carving has a different occurrence pattern to other common NSSIs and may be qualitatively different; and low prevalence NSSI methods tend to involve specific tools and may be more dangerous than other methods. Participants also considered some behaviours as NSSI, which are not consistent with this construct. Finally, when there is an established pattern of NSSI, frequency reports may not be exact, and number of methods engaged in may be an equally important indicator of severity. These findings highlight the need for comprehensive assessment when working with people who self-injure. Future research examining functional differences between various NSSI methods is indicated. This may be particularly important in identifying whether word carving and severe NSSI (such as bone breaking) are qualitatively different from common NSSI methods (such as cutting). Further research with representative samples can also clarify whether there are genuine differences in NSSI methods between Western countries, such as the United States and Australia, helping to clarify if there are cultural variations in these behaviours. Acknowledgements Acknowledgements must go to Professor Kim Gratz for supplying the Deliberate Self-Harm Inventory to the authors; Professor Marita McCabe for her helpful feedback regarding the larger study design; and to the participants for taking the time to share their information. References Aizenman, M., & Conover Jensen, M. A. (2007). Speaking through the body: The incidence of self-injury, piercing, and tattooing among college students. Journal of College Counseling, 10, doi: /j tb00004.x American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association. Andover, M. S. (2014). Non-suicidal self-injury disorder in a community sample of adults. Psychiatry Research, 219(2), doi: /j.psychres Andrews, T., Martin, G., Hasking, P., & Page, A. (2013). Predictors of continuation and cessation of nonsuicidal 2016 The Australian Psychological Society 43

8 Black and Mildred self-injury. Journal of Adolescent Health, 53, doi: /j.jadohealth Anestis, M. D., Khazem, L. R., & Law, K. C. (2015). How many times and how many ways: The impact of number of nonsuicidal self-injury methods on the relationship between nonsuicidal self-injury frequency and suicidal behavior. Suicide and Life-Threatening Behavior, 45, doi: /sltb Armiento, J. S., Hamza, C. A., & Willoughby, T. (2014). An examination of disclosure of nonsuicidal self-injury among university students. Journal of Community and Applied Social Psychology, 24, doi: /casp.2190 Barrocas, A. L., Hankin, B. L., Young, J. F., & Abela, J. R. Z. (2012). Rates of nonsuicidal self-injury in youth: Age, sex, and behavioral methods in a community sample. Pediatrics, 130, doi: /peds Black, E. B., & Mildred, H. (2014). A cross-sectional examination of non-suicidal self-injury, disordered eating, impulsivity, and compulsivity in a sample of adult women. 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9 NSSI characteristics St. Germain, S. A., & Hooley, J. M. (2012). Direct and indirect forms of non-suicidal self-injury: Evidence for a distinction. Psychiatry Research, 197(1 2), doi: /j.psychres Straiton, M., Roenb, K., Dieserudc, G., & Hjelmelandd, H. (2013). Pushing the boundaries: Understanding self-harm in a non-clinical population. Archives of Psychiatric Nursing, 27, doi: /j.apnu Swannell, S. V., Martin, G. E., Page, A., Hasking, P., & St John, N. J. (2014). Nonclinical samples: Systematic review, meta-analysis and meta-regression. Suicide and Life- Threatening Behavior, 44, doi: /sltb Turner, C. F., Al-Tayyib, A., Rogers, S. M., Eggleston, E., Villarroel, M. A., Roman, A. M., Cooley, P. C. (2009). Improving epidemiological surveys of sexual behaviour conducted by telephone. International Journal of Epidemiology, 38, doi: /ije/dyp210 Whitlock, J. L., Powers, J. L., & Eckenrode, J. (2006). The virtual cutting edge: The internet and adolescent selfinjury. Developmental Psychology, 42, doi: / Zetterqvist, M., Lundh, L.-G., Dahlstrom, O., & Goran Svedin, C. (2013). Prevalence and function of non-suicidal self-injury (NSSI) in a community sample of adolescents, using suggested DSM-5 criteria for a potential NSSI disorder. Journal of Abnormal Child Psychology, 41, doi: /s The Australian Psychological Society 45