Psychiatric Correlates of Nonsuicidal Cutting Behaviors in an Adolescent Inpatient Sample

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1 Child Psychiatry Hum Dev (2008) 39: DOI /s ORIGINAL ARTICLE Psychiatric Correlates of Nonsuicidal Cutting Behaviors in an Adolescent Inpatient Sample Lance P. Swenson Æ Anthony Spirito Æ Jennifer Dyl Æ Jennifer Kittler Æ Jeffrey I. Hunt Published online: 22 March 2008 Ó Springer Science+Business Media, LLC 2008 Abstract This archival study of 288 adolescent psychiatric inpatients examined the psychiatric correlates of cutting behavior. Participants were categorized into Threshold cutters (n = 61), Subthreshold cutters (n = 43), and Noncutters (n = 184). Groups were compared on psychiatric diagnoses, suicidality, and self-reported impairment. Results demonstrated that females were more likely to cut relative to males; however, gender did not affect the correlates of cutting behavior. Adolescents in the Threshold group were more likely to be diagnosed with Major Depression and had higher self-reported suicidality, depression, and trauma-related symptoms of depression and dissociation relative to the Noncutting group. The Subthreshold group did not differ from the other groupings except for an elevated risk for Posttraumatic Stress Disorder compared to the Noncutting group. Keywords Self-cutting Adolescents Gender Psychiatric correlates Nonsuicidal self-injurious behavior (NSSI), also known as self-mutilation [1], refers to purposeful damaging of body tissue without the intent to die [2, 3]. Adolescence is a period of particular risk for NSSI [4 7]. Studies of NSSI in community-based adolescent samples reveal prevalence rates of 1 14% [8, 9], compared to rates of 4% among adults [10]. Among treatment-seeking adolescents, prevalence rates of 38 61% have been reported [11, 12]. Of particular concern, findings from both community and clinical populations L. P. Swenson A. Spirito Center for Alcohol and Addiction Studies, The Warren Alpert Medical School at Brown University, Box G-121-4, Providence, RI 02912, USA Lance_Swenson@Brown.edu J. Dyl J. Kittler J. I. Hunt The Warren Alpert Medical School at Brown University and the Bradley Hospital, Providence, RI, USA J. I. Hunt (&) Bradley Hospital, 1011 Veterans Memorial Parkway, East Providence, RI 02915, USA JHunt@Lifespan.org

2 428 Child Psychiatry Hum Dev (2008) 39: document relations between adolescent NSSI and depression and anxiety [9, 11 15], oppositional/conduct problems [11, 14 17], substance abuse [14, 18], suicidality [12, 13, 19], and a history of abuse [20, 21]. Cutting (i.e., nonlifethreatening carving on the skin) is widely recognized as the most common form of adolescent NSSI, occurring in 14 65% of community-based adolescent NSSI samples [8, 13, 15, 17] and between 42 98% of clinical NSSI populations [12, 22, 23]. Relatively little research has investigated the psychological correlates specific to cutting even though cutting has been proposed to serve different functions, and may be associated with different correlates, compared to other forms of NSSI (e.g., head-banging) [24]. Kumar and colleagues [25], in one of the few studies focused on adolescent cutting, found that both the number and intensity of reasons for cutting were related to depression. Similarly, Rodham and colleagues [8] found that female cutters were more likely than male cutters to endorse selfpunishment and obtaining relief from distress to explain their cutting behavior. In addition, Fortune [22] found that adolescent outpatients with a history of cutting were more likely to report previous suicidal ideation relative to those who engaged in other forms of NSSI. Although NSSI more generally and cutting specifically is described as a repetitive act [2, 24], variability in the frequency and intensity of NSSI exists. However, researchers often ignore this fact. Instead, adolescents with differing histories of NSSI engagement are typically examined as a single group [e.g., 12] or are selected based upon the frequency with which they engage in NSSI [e.g., 25]. Nock and colleagues [14] found that the number of NSSI methods used and the number of years engaging in NSSI were related to number of lifetime suicide attempts (rs =.23 and.30, respectively). The number of distinct NSSI episodes, on the other hand, was not related to lifetime suicide attempts. Importantly this study did not examine repeated cutting specifically and instead focused on NSSI more generally [14]. The present, archival study of an adolescent psychiatric inpatient sample examines psychiatric impairment related to differing levels of engagement in cutting behavior. We hypothesized that adolescents with a history of cutting would endorse elevated symptoms of impairment across domains and would evidence greater psychiatric comorbidity compared to adolescent inpatients with no cutting history. In addition, we expected repetitive/ severe cutters to evidence elevated psychopathology, in terms of diagnosis and selfreported impairment, compared to infrequent/minor cutters. Method Participants Participants included 288 adolescent inpatients (64% female) at a psychiatric hospital located in the Northeast. They were selected from 401 consecutive admissions between March 2004 July Patients were excluded if they did not complete either the diagnostic interview or the intake battery (i.e., due to unexpected discharge or refusal to cooperate; n = 56), due to active psychosis or significant cognitive impairment (n = 34), or if there was insufficient information to determine whether the participant engaged in cutting (n = 5). Also, patients who reported only minor/infrequent cutting occurring more than 2 years prior to their admission were excluded (n = 18). Participants were 11 to 18 years old (M = 14.91; SD = 1.47). Self-identified racial/ethnic background was 72% Caucasian, 10% Hispanic/Latino, 6% African American, 2% Asian American, and 6% other (e.g., mixed ethnicity). The hospital from which the participants were drawn mainly serves patients of lower and middle socioeconomic status.

3 Child Psychiatry Hum Dev (2008) 39: Procedures The diagnostic interview and the self-report rating scales described below were administered by trained mental health workers as part of the standard intake battery. Participants were assessed within 1 week of admission, typically within the first three days. Demographic information, current and lifetime cutting behavior, and current and lifetime suicidality were collected via chart reviews. Cutting history and history of suicidality were documented in several reports (i.e., intake, psychosocial history, psychiatric interview). The hospital Human Subjects Review Committee permitted the use of this archival data. Measures Cutting Group Classification Chart reviews assessed current and lifetime cutting behaviors using the non-suicidal physical self-damaging acts module of the Schedule for Affective Disorders and Schizophrenia for School Aged Children (K-SADS-PL) [26]. Consistent with the K-SADS-PL scoring criteria, adolescents who had cut themselves four or more times or had caused injury requiring medical intervention and who had engaged in at least one episode of cutting in the past 2 years were categorized as Threshold cutters (n = 61; 21%). Adolescents with 1 3 cutting episodes, at least one of which occurred within the past 2 years, and whose cutting had not caused serious injury were categorized as Subthreshold cutters (n = 43; 15%). Adolescents with no history of cutting were categorized as Noncutters (n = 184; 64%). Cutting behaviors reported as suicide attempts were not considered. Separate reviews were conducted by two authors (AS and JK) blind to patients responses to assessment measures. Discrepancies (n = 43) were resolved by a third independent rater (JD). Children s Interview for Psychiatric Symptoms (ChIPS) [27] The ChIPS is a structured clinical interview that screens for 20 DSM-IV Axis I disorders. Validation studies demonstrate adequate sensitivity and specificity in relation to clinician diagnoses as well as concurrent validity in comparison to the DICA [27] and to the K-SADS-PL [28]. Consensus DSM-IV diagnoses were made by a clinical team using the results of the ChIPS and all available clinical data (i.e., the full assessment battery and the complete medical record). Similar best-estimate clinical consensus procedures have been shown to yield good to excellent reliability [29, 30]. Suicide Probability Scale (SPS) [31] The SPS is a 36-item self-report measure of feelings/behavior related to suicidality. Items are rated on a 4-point scale ranging from none or little of the time to most or all of the time. The SPS yields a total score and four subscales (i.e., hopelessness, suicidal ideation, negative self-evaluation, and hostility). Higher scores indicate greater suicidality. The SPS has adequate internal consistency (total score a =.93; subscale as =.62.89), split-half reliability (r =.93), and test retest reliability (r =.92) [31].

4 430 Child Psychiatry Hum Dev (2008) 39: Reynolds Adolescent Depression Scale-2 (RADS-2) [32] The RADS-2 is a 30-item self-report measure of depressive symptoms. Items are rated on 4-point scale ranging from almost never to most of the time and are summed to create a total symptoms score. The RADS-2 has shown adequate internal consistency (a =.92) and test retest reliability (r =.80) [32]. Self-Perception Profile for Children (SPPC) [33] The SPPC is a 28-item self-report measure assessing perceived competence and self-worth with five subscales: social acceptance, athletic competence, physical appearance, romantic appeal, and close friendships. The subscales have shown adequate internal consistency (subscale as =.85.95) [33]. Trauma Symptom Checklist for Children (TSCC) [34] The TSCC is a 55-item measure assessing trauma-related symptoms. Items are rated on a 4-point rating scale. The measure yields two validity scales (i.e., under-reporting, hyperreporting) and six clinical scales (i.e., anxiety, depression, anger, posttraumatic stress, dissociation [with two subscales: overt and fantasy], and sexual concerns [with two subscales: preoccupations and distress]). Research conducted by the developers has shown adequate internal consistency (subscale as =.82.89) as well as evidence for construct and convergent validity [34]. Hopelessness Scale for Children (HSC) [35] The HSC includes 17 true/false statements assessing negative expectancies about oneself and one s future, with higher scores indicating increased hopelessness. Research conducted by the developers of the inventory reported internal consistency a =.97 and test retest reliability r =.52. The HSC also has shown adequate construct validity with child and adolescent psychiatric patients [35, 36]. Multidimensional Anxiety Scale for Children Short Version (MASC-10) [37] The MASC-10 is a 10-item rating scale that screens for physical symptoms of anxiety, harm avoidance, social anxiety, and separation/panic. Items are rated on a 4-point rating scale ranging from never true about me to often true about me. The MASC-10 has adequate internal consistency (a =.87) and test retest reliability (r =.83) [37]. State-Trait Anger Expression Inventory (STAXI) [38] The STAXI is a 44-item, 4-point rating scale assessing control of and expression of anger. Items are rated on a 4-point scale, with higher scores indicating greater intensity/frequency of anger experienced or expressed. The measure consists of seven subscales (i.e., state anger, trait anger, angry temperament, angry reaction, anger in, anger out, and anger control) as well as an index of anger expression frequency. Adequate psychometric properties have been reported, and the inventory has been validated with both normal and clinical populations [38].

5 Child Psychiatry Hum Dev (2008) 39: Results In the first major subsection of the Results presented below, the representativeness of the sample retained for analyses is examined. Potential demographic differences among the three cutting group classifications (i.e., Noncutters, Subthreshold, and Threshold) also are examined in this section. Next, cutting group differences in risk for Axis I psychiatric diagnoses were tested. Third, cutting group differences in suicidality were examined. In the fourth subsection, potential cutting group differences in self-reported psychiatric impairment were examined. Representativeness of the Retained Sample A series of t-tests and chi-square analyses were conducted to assess demographic differences between participants who were included in this study (n = 288) versus those who were excluded (n = 113). No differences were evident for sex (v 2 [2] = 1.18, p = 0.28), age (F [1, 399] =.20, p = 0.65), or race/ethnicity (i.e., white vs. nonwhite; v 2 [2] = 2.26, p = 0.13). Analyses also compared the Noncutting, Subthreshold, and Threshold cutting groupings on sex, age, and race/ethnicity. No differences were evident for age (F [2, 287] =.28, p = 0.75), or race/ethnicity (i.e., white vs. nonwhite; v 2 [2] = 4.05, p = 0.13). Girls were more likely to be classified as Subthreshold and Threshold cutters than were boys (79% and 80% female, respectively) compared to the Noncutting group (55% female), v 2 (2) = 17.90, p \ Psychiatric Diagnoses and Cutting Behavior Table 1 presents the frequencies of DSM-IV diagnoses for the three cutting groupings. Anxiety disorders were relatively rare (ranging from 0.3% for Phobia to 2.8% for Generalized Anxiety Disorder). Therefore, diagnoses of Generalized Anxiety Disorder, Obsessive Compulsive Disorder, Phobia, Social Phobia, Separation Anxiety Disorder, Panic Disorder, and Anxiety Disorder NOS were aggregated into an Anxiety Disorders composite. Cutting group differences in psychiatric diagnoses were evaluated using logistic regressions controlling for gender. Adolescents in the Threshold group were more likely than those in the Noncutting group to meet criteria for Major Depression, Wald v 2 (1) = 4.05, p \ 0.05 (see Table 1). The Subthreshold group did not differ from either the Threshold (Wald v 2 [1] = 1.11, p = 0.29) or the Noncutting groups (Wald v 2 [1] =.33, p = 0.57) in risk for being diagnosed with Major Depression. Adolescents in the Subthreshold cutting group were at significantly greater risk for being diagnosed with Posttraumatic Stress Disorder (PTSD) compared to the Noncutting group, Wald v 2 (1) = 5.59, p \ The Threshold group did not differ from either the Subthreshold (Wald v 2 [1] = 1.27, p = 0.26) or the Noncutting groups (Wald v 2 [1] = 1.44, p = 0.23) in risk for being diagnosed with PTSD. Adolescents in the Threshold group were significantly more likely than the Noncutting group to meet criteria for an eating disorder, Wald v 2 (1) = 1.01, p \ The Subthreshold group did not differ from the Threshold group (Wald v 2 [1] =.56, p = 0.46), and the differences between the Noncutting and the Subthreshold groups approached but did not reach significance, Wald v 2 (1) = 3.71, p = However, it should be noted

6 432 Child Psychiatry Hum Dev (2008) 39: Table 1 Prevalence rates of psychiatric diagnoses of the noncutting, subthreshold, and threshold cutting groups (n = 288) Noncutting N (%) Subthreshold N (%) Threshold N (%) Subthreshold vs. Noncutting Odds ratio (95% CI) Threshold vs. Noncutting Odds ratio (95% CI) Subthreshold vs. Threshold Odds ratio (95% CI) Major depression 49 (26.8) 16 (37.2) 27 (44.3) 1.27 ( ) 2.06 ( ) 1.62 ( ) Bipolar disorder 24 (13.1) 5 (11.6) 10 (16.7) 1.06 ( ) 1.20 ( ) 1.33 ( ) Any anxiety disorder 37 (20.2) 10 (23.3) 11 (18.0).87 ( ).65 ( ).75 ( ) Posttraumatic stress disorder 36 (19.6) 15 (34.9) 14 (23.0) 2.82 ( ) 1.65 ( ).58 ( ) Eating disorder 1 (0.5) 3 (7.0) 7 (11.5) 9.58 ( ) ( ) 1.72 ( ) Attention-deficit/hyperactivity disorder 38 (20.8) 7 (16.2) 13 (21.3) 1.74 ( ) 2.59 ( ) 1.49 ( ) Oppositional defiant disorder 21 (11.5) 6 (14.0) 4 (6.6) 1.11 ( ) 1.02 ( ).92 ( ) Conduct disorder 30 (16.4) 2 (4.7) 5 (8.2).35 ( ).24 ( ).69 ( ) Substance abuse 19 (10.4) 5 (11.6) 12 (19.7) 1.35 ( ) 2.28 ( ) 1.69 ( ) Notes: Consensus diagnoses, using DSM-IV criteria were made by a clinical team using all available data, including the Children s Interview for Psychiatric Syndromes and each participant s complete medical record. Any Anxiety Disorder aggregates diagnoses of Generalized Anxiety Disorder, Obsessive Compulsive Disorder, Phobia, Social Phobia, Separation Anxiety Disorder, Panic Disorder, and Anxiety Disorder NOS. Odds ratios were calculated in logistic regressions controlling for gender. Odds ratios that are bolded are significant at p \ 0.05

7 Child Psychiatry Hum Dev (2008) 39: Table 2 Suicidality of the noncutting, subthreshold, and threshold cutting groups (n = 288) Noncutting N (%) Subthreshold N (%) Threshold N (%) Subthreshold vs. Noncutting Odds ratio (95% CI) Threshold vs. Noncutting Odds ratio (95% CI) Subthreshold vs. Threshold Odds ratio (95% CI) Suicidality on admission Ideator/ threatener 63 (41.4) 22 (56.4) 30 (66.7) 1.12 ( ) 1.94 ( ) 1.74 ( ) Attempter a 29 (16.0) 2 (4.9) 11 (19.6) Lifetime history of 1+ suicide attempts 19 (10.4) 5 (11.6) 12 (19.7).69 ( ) 1.38 ( ) 1.99 ( ) Repeated (2 + ) attempts 26 (44.8) 6 (50.0) 14 (50.0).74 ( ) 1.25 ( ) 1.68 ( ) a Potential group differences were not tested as the Subthreshold grouping included \5 participants that all of the participants diagnosed with an eating disorder (n = 11) were female, and recall that girls were more likely to cut than were boys. There were no significant differences in the prevalence rates of Bipolar Disorder, Anxiety Disorders, Attention-Deficit/Hyperactivity Disorder, ODD, CD, or Substance Abuse. Also, none of the gender by cutting interaction terms significantly predicted any psychiatric diagnosis (all Wald v 2 s \ 3.50, all ps C.18). In addition, the cutting groups did not differ on the overall number of DSM-IV diagnoses identified, F (2, 281) = 2.00, p = 0.14 (M Noncutting = 1.56 [SD =.85], M Subthreshold = 1.79 [SD =.80], M Threshold = 1.75 [SD =.96]). Suicidality and Cutting Behavior Logistic regressions, controlling for gender, were conducted to examine differences between the Noncutting, Subthreshold, and Threshold groupings for current suicidality and for lifetime suicide attempts (see Table 2). The cutting groups were not found to differ significantly in suicidal ideation at time of admission, in history of attempted suicide, or in history of repeat (2+) suicide attempts (all Wald v 2 s \ 2.39, all ps C.12). In addition, the gender by cutting group interaction did not predict any index of suicidality (all Wald v 2 s \ 1.58, all ps C.45). Self-Reported Impairment and Cutting Behavior A series of 2 (Gender Male/Female) 9 3 (Cutting Noncutting, Subthreshold, Threshold) way ANOVAs were conducted to assess cutting group differences in selfreported psychological impairment (see Table 3). Significance for these analyses was set at p \ to control for Type I error. Results demonstrated that adolescents in the Threshold group scored significantly higher than the Noncutting group on the SPS hopelessness and suicidal ideation subscales, the SPS total score, the RADS, and on the TSCC depression and dissociation subscales. Of note, the Subthreshold group did not differ from the Threshold or the Noncutting groupings on any self-report measure of impairment. In addition, the gender by cutting group interaction term did not significantly predict any index of self-reported impairment.

8 434 Child Psychiatry Hum Dev (2008) 39: Table 3 Means, standard deviations, and Ns for the self-report measures of impairment by cutting group Noncutting Sub-threshold Threshold F M SD N M SD N M SD N Suicide probability scale Hopelessness * Suicide ideation * Negative SE Hostility Total * Reynolds adolescent depression scale * Self-perception profile for children Social acceptance Athletic competence Physical appeal Romantic appeal Close friendships Trauma symptom checklist for children Under-reporting Hyper-reporting Anxiety Depression * Anger PTSD Dissociation * Dissociation Overt Dissociation Fantasy Sexual Concerns Sexual concerns Preoccupations Sexual concerns Distress Hopelessness scale for children Multidimensional anxiety scale for children State/trait anger expression inventory State anger Trait anger Angry temperament Angry reaction Anger in Anger expression Anger control Anger expression frequency Note: Significance was set at p \ to control for Type I error. Statistically significantly differences between the Noncutting and the Threshold Cutting Groups are bolded. The Subthreshold group did not significantly differ from either the Noncutting or Threshold groups for any self-reported index of impairment. * p \ 0.001

9 Child Psychiatry Hum Dev (2008) 39: Discussion The present study examined cutting behavior in adolescent psychiatric inpatients and compared subgroups of adolescents with differing histories of cutting behavior on DSM-IV diagnoses, on suicidal ideation and behavior, and on self-report measures of impairment. Approximately 36% of the adolescent inpatients had documented histories of recent (i.e., within the past 2 years) cutting behaviors. Of these, 59% (21% of the total sample) exhibited recurrent or severe (i.e., wounds requiring medical intervention) cutting. The prevalence of cutting in the current sample is comparable to rates observed in other adolescent inpatient samples (e.g., 26 38%) [12, 23] and significantly higher than rates seen in community-based adolescent populations (e.g., %) [13, 15]. The results indicated that adolescents with a more extensive degree of self-cutting (i.e., Threshold cutters) evidenced more symptoms of depression and trauma-related dissociation and were more likely to be diagnosed with Major Depression relative to adolescents who do not engage in cutting. These results are largely consistent with the growing body of literature examining adolescent NSSI and with evidence showing that a primary reason for engaging in NSSI behaviors is to reduce feelings of depression or negative affect [8, 12, 13, 23]. Importantly, the inclusion of a non-harming control group from the same psychiatric facility helps to ensure that these results were not due to potential differences in psychological distress more generally. Although adolescents in the Threshold cutting group reported higher levels of suicidal ideation on the SPS relative to the Noncutting group, the cutting groups were not found to differ with regard to suicidal behavior. These findings are consistent with work by Muehlenkamp and Gutierrez [39], who found that adolescents with a history of NSSI reported a greater attraction to life relative to adolescents with a history of suicidal behavior. Relatedly, Patton and colleagues [15] found that most adolescents who engage in some form of NSSI do not perceive death as a likely result of their self-harming behavior. The lack of cutting group differences in suicidal behavior evident in the present research are in line with these prior findings and provide further support for the distinction between NSSI and suicidality [2, 6, 40, 41]. Adolescents with limited histories of cutting (i.e., the Subthreshold group) generally did not differ from either the noncutters or those with more extensive cutting histories. However, adolescents in the Subthreshold cutting group were nearly three times as likely to meet diagnostic criteria for PTSD relative to the adolescent inpatients with no history of cutting behavior. Relations between experiencing abuse or a trauma and NSSI have been found in similar studies [20]. It is unclear why adolescents engaging in more severe or repetitive cutting (i.e., Threshold cutters) did not exhibit increased risk for PTSD. One possibility is that cutting may initially be undertaken as maladaptive coping strategy for dealing with childhood trauma. As cutting becomes increasingly repetitive, however, alternate motivations (such as negative affect regulation [23], or potentially addictive aspects of repetitive NSSI [12]) may become the primary forces compelling continued cutting behavior. The findings also have implications for understanding relations between gender and cutting. In the present study females were significantly more likely to have documented histories of cutting than were boys. This finding is consistent with some prior research using both community-based [e.g., 9, 15] and clinical adolescent samples [e.g., 7]. However, other studies have found males were as likely as females to engage in NSSI [12 14, 22, 23]. One possibility for these discrepant findings may derive from the considerable variation across studies in the behaviors categorized as NSSI [e.g., 13], whereas the present study focused specifically on cutting (a method of NSSI hypothesized to be particularly

10 436 Child Psychiatry Hum Dev (2008) 39: common among psychiatrically-impaired females) [41]. Importantly, the psychiatric correlates of cutting behavior were found to be similar for female and male cutters (i.e., all of the gender X cutting group interaction terms were nonsignificant). Cumulatively these findings suggest that, although important gender differences exist with regards to prevalence, the consequences of cutting behavior may act independently of whether the adolescent in question is male or female. Limitations A few limitations should be noted. First, the sample was limited to adolescents admitted to a psychiatric unit. Second, the assessment of cutting behavior (i.e., archival chart review) precluded the collection of other factors of import for understanding self-cutting, such as the motivations for engaging in NSSI [1, 17, 25] or the contextual features associated with the cutting episodes. Third, this study did not consider Axis II diagnoses. Features of personality disorders, in particular characteristics of Borderline Personality Disorder, are common in adults who self-injure [2, 41], and recent evidence finds elevated rates of axis II symptomatology among female adolescent inpatients who engage in NSSI [14]. Future research could build upon the present findings by evaluating whether adolescents who engage in differing degrees of cutting behavior evidence differing risk for an Axis II diagnosis. Fourth, the investigation was cross-sectional; the direction of effects could not be ascertained. In addition, the focus on cutting precluded examining whether adolescents engaged in other types of NSSI (e.g., burning) during the time frame considered. Further work employing a prospective design could clarify temporal relations as well as the psychiatric course of adolescents who differ in cutting behavior while controlling for additional methods of NSSI. It should also be noted that the small sample size available for analyses precluded examining differences across specific racial or ethnic groups. Summary The psychiatric correlates of engaging in differing levels of cutting were examined in this archival study of 288 adolescent psychiatric patients. Results indicated that both male and female adolescent inpatients with more extensive histories of cutting (i.e., Threshold cutters) were more likely to be diagnosed with Major Depression and reported greater suicidality and trauma-related symptoms of depression and dissociation relative to adolescent inpatients with no history of cutting (i.e., the Noncutting group). Of note, adolescents with relatively limited histories of cutting (i.e., the Subthreshold group) did not differ from either the Threshold or the Noncutting groupings except for an elevated risk for PTSD compared to the Noncutting group. This pattern suggests that psychiatric impairment may become progressively more evident as cutting behavior becomes increasingly repetitive and/or severe. Alternatively, it is possible that increased psychiatric impairment may result in a subgroup of adolescents (i.e., Threshold cutters) who repeatedly use cutting as a maladaptive coping strategy for dealing with distress. Intervening with adolescents who engage in cutting early in their self-harming trajectory (e.g. providing more effective strategies to cope with negative affect) may help prevent an escalation in their self-injurious behavior. References 1. Nock MK, Prinstein MJ (2005) Contextual features and behavioral functions of self-mutilation among adolescents. J Abnorm Psychol 114:

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