Meszaros et al. BMC Psychiatry (2017) 17:160 DOI 10.1186/s12888-017-1326-y

RESEARCH ARTICLE Open Access Self-injury and externalizing pathology: a systematic literature review Gergely Meszaros1,2* , Lili Olga Horvath3,4 and Judit Balazs2,4

Abstract Background: During the last decade there is a growing scientific interest in nonsuicidal self-injury (NSSI). The aim of the current paper was to review systematically the literature with a special focus on the associations between self- injurious behaviours and externalizing psychopathology. An additional aim was to review terminology and measurements of self-injurious behaviour and the connection between self-injurious behaviours and suicide in the included publications. Methods: A systematic literature search was conducted on 31st December 2016 in five databases (PubMed, OVID Medline, OVID PsycINFO, Scopus, Web of Science) with two categories of search terms (1. nonsuicidal self-injury, non-suicidal self-injury, NSSI, self-injurious behaviour, SIB, deliberate self-harm, DSH, self-injury; 2. externalizing disorder, attention deficit hyperactivity disorder, ADHD, conduct disorder, CD, oppositional defiant disorder, OD, ODD). Results: Finally 35 papers were included. Eleven different terms were found for describing self-injurious behaviours and 20 methods for measuring it. NSSI has the clearest definition. All the examined externalizing psychopathologies had strong associations with self-injurious behaviours according to: higher prevalence rates in externalizing groups than in control groups, higher externalizing scores on the externalizing scales of questionnaires, higher symptom severity in self-injurious groups. Eight studies investigated the relationship between suicide and self- injurious behaviours and found high overlap between the two phenomena and similar risk factors. Conclusions: Based on the current findings the association between externalizing psychopathology and self-injurious behaviours has been proven by the scientific literature. Similarly to other reviews on self-injurious behaviours the confusion in terminology and methodology was noticed. NSSI is suggested for use as a distinct term. Further studies should investigate the role of comorbid conditions in NSSI, especially when internalizing and externalizing pathologies are both presented. Keywords: NSSI: nonsuicidal self-injury, DSH: deliberate self-harm, SIB: self-injurious behaviour, self-injury, externalization, ADHD: attention deficit hyperactivity disorder, CD: conduct disorder, ODD: oppositional defiant disorder, psychopathology, psychiatric disorder

Background chapter ‘Conditions for Further Study’. The definition In the past decade self-injury became a hot topic in sci- for NSSI in DSM-5 follows the main instructions of the entific literature. Nonsuicidal self-injury (NSSI) became definition of the ‘International Society for the Study of an individual diagnosis in the 5th edition of the Diagnos- Self-injury’ (ISSS), which was made in 2007 [2]. This def- tic and Statistical Manual of Mental Disorders [1]; for inition emphasizes the deliberate, nonsuicidal purpose of the present it can be found only in Section III in the the self-injurious act, which is not socially sanctioned. It underlines the importance to distinguish it from drug * Correspondence: [email protected] overdoses, culturally sanctioned behaviours (e.g. pierc- 1Semmelweis University, Mental Health Sciences School Of Ph.D., Üllői út 26, ings), and repetitive, stereotypical forms among people Budapest 1085, Hungary with developmental disorders [2]. The DSM-5 suggests 2Vadaskert Child Psychiatry Hospital and Outpatient Clinic, Lipótmezei út 1-5, Budapest 1021, Hungary as a criterion of NSSI, that self-injurious acts should Full list of author information is available at the end of the article

© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Meszaros et al. BMC Psychiatry (2017) 17:160 Page 2 of 21

happen on at least 5 days in the past year. Moreover the important to review: 2) terminology and definitions of DSM-5 underlines the non adaptive ‘coping strategy’ self-injurious behaviour, and 3) methods for measuring it. nature of NSSI: the individual who engages in NSSI Finally, we examined: 4) associations between self-injury must have the aim to get to a better emotional state after and suicide among the included publications. the action [1]. In the 4th edition of DSM [3], deliberated NSSI can only be found as a symptom of borderline personality Methods disorder (BPD), however clinicians can meet a lot of pa- A systematic literature search was made on 31th Decem- tients with self-injury without BPD as well. Glenn and ber 2016 in five computerised literature databases: Klonsky [4] found in an adolescent psychiatric sample PubMed, OVID Medline, OVID PsycINFO, Scopus, that the coexistence of NSSI and BPD is not more com- Web of Science. Search terms were: ‘(nonsuicidal self- mon than the coexistence of any other Axis I diagnoses injury OR non-suicidal self-injury OR NSSI OR self- and NSSI. Zetterqvist [5] found that in the population injurious behaviour OR SIB OR deliberate self-harm OR who met NSSI DSM-5 criteria there are more general DSH or self-injury) AND (externalizing disorder OR at- psychopathology and impairment, than in the population tention deficit hyperactivity disorder OR ADHD OR who did not present NSSI behaviour or in the popula- conduct disorder OR CD OR oppositional defiant dis- tion who present NSSI behaviour, but did not meet the order OR OD OR ODD)’. We found 902 papers in DSM-5 criteria. PubMed, 127 papers in OVID Medline, 120 papers in Several risk factors of NSSI are described, such as prior OVID PsycINFO, 116 papers in Web of Science and 16 history of NSSI, cluster b personality, hopelessness, female papers in Scopus, making a total of 1281 studies includ- gender, depression, prior suicidal thought/behaviour, ex- ing duplicates. We used EndNote X7 software for the posure to peer NSSI, eating disorder, abuse, etc. [6]. systematization of the papers. After a duplicate search Many studies examined the association between NSSI (both automatic by the software and manual by reading and internalizing pathology; recently Bentley et al. [7] the authors and the titles again) we excluded 222 arti- summarized these studies in their meta-analytic review: all cles, so altogether we had 1059 individual papers (see the examined emotional disorders had an increased odds the details in Fig. 1). ratio for NSSI, except for bipolar disorder and social anx- The flowchart of the inclusion/exclusion process can iety disorder. The association was the strongest with panic be seen in Fig. 2. Inclusion criteria were that studies in- and post-traumatic stress disorder, otherwise there were vestigating self-injury and externalizing pathology (a), no significant differences between the emotional disor- are written in English (b), and reported original data (c). ders. Inconsistent methodologies are emphasized, such as Exclusion criteria were studies: that were not written in the wide range of instruments used to assess NSSI and the English (b), were review/meta-analysis (c), were not multiple terms for self-injury, including NSSI. about psychiatry/psychology (d), were not about self- The association between externalizing pathology and injury (e), were not about externalizing pathology correl- NSSI are understudied. Although Fox et al. [6] found ation (f). that the odds ratios of ‘misc externalizing symptoms’ is A QUORUM flowchart of the selection process is higher (1.68) than ‘misc internalizing symptoms’ (1.37). summarized in Fig. 1. Publications included in the sys- According to our knowledge, there is only one review tematic review were selected in three steps: 1) from the that investigated a specific externalizing disorder (atten- 1059 individual papers, based on their titles 767 publica- tion deficit hyperactivity disorder – ADHD) and its asso- tions were excluded, 2) from the remaining 292, based ciation with self-injury, and found that ADHD is a risk on their abstracts 232 more were excluded 3) from the factor of self-harm [8]. remaining 60 papers, 26 more were excluded after read- Therefore, our aim is to systematically review the stud- ing their full-texts. Finally, we added 1 paper by manual ies that examined the association between self-injurious search. Therefore, a total of 35 papers are included in behaviour and externalizing psychopathology. Not only our systematic review (Table 1). First, each paper’s title, ‘NSSI’ was chosen as a search word for self-injurious be- abstract and full-text was investigated by the first author, haviour, because the scientific literature is very confused which process was blinded reviewed by the second au- about the terms [9]. Moreover, e.g. Brunner, Kaess et al. thor. When there was a disagreement between the first [10] noted this important aspect, often in clinical prac- and second authors whether a paper should be included tice it is hard to distinguish the purpose of a self- or excluded to the systematic review, a common discus- injurious act. sion and a final collective decision was made by all the Before investigating the main aim of our study – 1) three authors. prevalence rates, odds ratios or other associations between The methodology of this systematic descriptive review externalizing pathology and self-injury – it seemed to be follows the PRISMA guidelines. Meszaros et al. BMC Psychiatry (2017) 17:160 Page 3 of 21

Fig. 1 QUORUM flowchart

Results deliberate self-poisoning; EDR: electrodermal responding; Summary of included papers in the review. Abbreviations: FASM: Functional Assessment of Self-Mutilation; FU: ADD: attention deficit disorder; ADHD: attention deficit follow-up; IED: intermittent explosive disorder; LPC: Life- hyperactivity disorder; BL: baseline; BPD: borderline per- time Parasuicide Count; L-SASI: Lifetime-Suicide Attempt sonality disorder; CD: conduct disorder; DSH: deliberate Self-Injury; MDD: major depressive disorder; NSSI: nonsui- self-harm; DSHI: Deliberate Self Harm Inventory; DSP: cidal self-injury; ODD: oppositional defiant disorder; PEP:

Fig. 2 Flowchart of inclusion/exclusion process Table 1 Included relevant articles examining associations between self-injury and externalizing pathology Meszaros Author, year Country Design Age group No of Terminology Distinction Measurement of Main results Externalization pathology participants for self betwen self-injurious and self-injury injurious suicidal or behaviours association Psychiatry BMC al. et behaviour non-suicidal intent Aglan et al. UK prospective; baseline: BL: M = 14.5; BL: 158; DSP No part of the The main risk factor for Conduct disorder is a risk (2008) [11] adolescents took part SD = 1.1; FU: FU: 126 interviewing repeated DSH is MDD. factor in their model to DSH in a family intervention; M = 20.8; process, However, adulthood adversity repetition in adulthood. follow up: six years SD = 1.1 question (DSH is included) is influenced Correlation coefficient: 0.17. later; self-poisoners for DSH by other risk factors such as: child sexual abuse and (2017)17:160 adolescent hopelessness and conduct disorder. Bacskai et al. Hungary cross sectional, drug M = 27; 210 self-injury Yes part of the The highest aggressive Physical self-injury is (2012) [18] dependent patients SD = 6.3 interviewing tendencies were shown by significantly more prevalent from outpatient drug process, the ADHD group. ADHD among substance dependent centers with and question for patients had higher levels of patients with ADHD than without ADHD self-injury depression, suicidality and without ADHD (X2 = 25.2; self-injury. p < 0.0001). Carli et al. Italy cross sectional, N.A. 1265 self-mutilation Yes part of the Psychoticism, extraversion, Prevalence of self-mutilation (2010) [19] incarcerated interviewing aggression, hostility and is significantly higher in volunteers process, resilience capacity were more high-impulsive group than question for frequent among high in low-impulsive group self-mutilation impulsive subjects. They (X2 = 9.27; p = 0.001), but engaged in self-mutilation there is no difference in the more frequently, substance level of suicidality. use disorder was also more frequent in this group. There was no difference between groups in suicidality. Cerutti et al. Italy cross-sectional, 13–22; 234 DSH Yes questionnaire for They found a correlation There was a strong correlation (2011) [20] normal population M = 16.47; DSH; DSHI between all the between DSH and CD/ODD SD = 1.7 psychopathologies examined: (correlation coeffitients: ODD: CD, ODD, BPD, dissociative 0,39; CD: 0.41; p < 0.01). There symptoms. They also found a were no differences in the correlation between DSH and levels of correlation between stressful life events DSH and CD and DSH and (psychological and sexual ODD. abuse, natural disasters and serious accidents, the loss of someone important, and the witnessing of family violence or a serious accident). Chou et al. Taiwan retrospective, Taiwanian <18; ADHD: 3685; 36,850 DSP No based on 50% of the NSSI group DSP incidence was (2014) [12] National Healthcare M = 8.5; clinical data engaged in this behaviour significantly higher in the Insurance Database; SD = 3.0; once or twice; 36% four times ADHD group than in patients with ADHD, HC: M = 8.4; or more. No self-harm group: comparsion group. Adjusted matched controls; SD = 3.0 lowest levels of risk factors, hazard ratio: 4.65 (95% CI: 21 of 4 Page 3 years interval highest levels of protective 2.41–8.94); p < 0.05. factors. Adolescents in the NSSI group had fewer depressive symptoms, lower Table 1 Included relevant articles examining associations between self-injury and externalizing pathology (Continued) Meszaros

suicidal ideation, greater self-esteem and parental support than the suicide Psychiatry BMC al. et attempt group. Crowell et al. USA cross-sectional, 14–18; 46 (23 + 23) parasuicide No interview for Adolescents with a history of There were significantly more (2005) [13] parasuicidal M = 15.3; parasuicide; LPC parasuicide showed reduced externalization symptoms in adolescents and SD = 1.1 RSA at baseline, greater RSA the parasuicidal than in the age matched reactivity during negative control group. According to controls mood induction. There were parent’s report: F = 39.3;

no differences between EDR according to self report: (2017)17:160 and PEP. These results support F = 26.6; according to theories that emphasize the teacher’s report: F = 17.2; importance of emotional p < 0,001. dysregulation and impulsivity in parasuicidal teenage girls. Crowell et al. USA cross-sectional with 2 13–17; 75 self-inflicted Yes interview for SII; The SII group had higher There were significantly more (2012) [21] phases: visit1: self- SII group: (25 + 25 + 25) injury (SII) L-SASI same as scores on both externalizing externalization symptoms in reported questionnaires; M = 16.3; LPC psychopathology and the self-injury group than in visit2: interview, SD = 1.0; emotion dysregulation, and the control group or in the physiological depressed group: had more attenuated EDR depressed group. According measurement; 3 groups: M = 15.4; than depressed adolescents. to parent’s report: F = 23.7; self-injuring, depressed, SD = 1.4; Self-injuring adolescents also according to self report: control females control: had higher scores on F = 34.5; p < 0.001. M = 16.1; borderline pathology. These SD = 1.3 findings show that there are differences between self-injuring and depressed adolescent girls in aetiology and developmental course. Darke and Australia cross-sectional, 21–62; 300 non-suicidal Yes part of the Childhood physical abuse was There were no significantly Torok (2013) IDU patients M = 37.1; self-harm interviewing reported in 74.3%. more CD symptoms among [22] SD = 7.9 process, Independent correlates of drug abuser patients with questions for non-suicidal self-harm were: non-suicidal self-harm than non-suicidal female gender, avoided home without non-suicidal self- self-harm due to conflict, more harm. Odds ratio: 1.74 (95% CI: extensive polydrug use. 0.97–3.14); non-significant. Independent correlates of attempted suicide were: severe childhood physical abuse, frequent abuse, avoided home due to conflict, female gender, a positive screen for CD, more extensive polydrug use. Evren et al. Turkey cross-sectional, M = 16.7; 4938 self-harm Yes part of a longer ADHD symptom scores were Sscores on the questionnaire (2014) [23] normal population SD = 6.4 questionnaire, higher in females and among measuring ADHD symptoms questions for adolescents who used were significantly higher in

self-harm tobacco, alcohol and drugs, the self-harming population 21 of 5 Page and had self-harming than in the non-self-harming behaviour and suicidal population (t = −15.38; thoughts in their lifetime. p < 0.001). ADHD symptom score was Table 1 Included relevant articles examining associations between self-injury and externalizing pathology (Continued) Meszaros

correlated with depression, anxiety, anger and sensation seeking scores, in ANCOVA Psychiatry BMC al. et ADHD symptom score correlated with depression, anxiety, anger, sensation seeking. Alcohol use and suicidal thoughts predicted the severity of ADHD.

Feingold Israel cross-sectional, general M = 15.8; 238 self-injury Yes based on Alcohol-abuse patients had There was significant (2017)17:160 et al. (2014) clinical sample, SD = 4.3 clinical data suicide attempts and self- difference in the prevalence [24] inpatients injurious acts more frequently of self-injurious behaviour than non-alcohol-abuse among alcohol abusers and patients. Attention-deficit non-abusers (X2 = 7.61; disruptive behaviour disorders, p < 0.05). Externalizing pathology criminal activity and drug use was also more common in were more common in the the alcohol abuser group abusers group. Median length (X2 = 6.29; p < 0.05). of stay in hospital was longer in the non-abuser group. Fulwiler et al. USA cross sectional, Self-mutilators: 31 self-mutilation Yes based on Suicide attempters frequently Childhood ADHD is associated (1997) [25] incarcerated population M = 30; clinical data had adult affective disorder. with self-mutilation among SD = 7.2; Self-mutilators more often had adult prisoners (X2 = 15.5; suicide a history of childhood p = 0.00008). attempters: hyperactivity and a mixed M = 34; dysthymia and anxiety that SD = 7.3 began in childhood or early adolescence. Garcia-Nieto Spain cross-sectional, clinical M = 43.3; 150 suicide Yes interview for Those who engaged in Antisocial personality disorder et al. (2014) sample, inpatients, who SD = 10.3 attempt, suicide suicidal gestures are more is a risk factor for suicidal [26] had self-injurious suicide gesture gestures; SITIBI likely to have a personality gestures. Odds ratio: 2.28 behaviours (NSSI + suicide disorder, especially from (CI 95%: 1.12–4.64); p < 0,05. attempt to Cluster B (histrionic and communicate antisocial). Narcissistic with others) personality disorder was a risk factor for suicide attempt, and borderline personality disorder was a risk factor for both. High impulsiveness was associated with suicide. Suicide attempts and suicide gestures are two distinct phenomena. Gatta et al. Italy case-control study, 12–17; NSSI 33 in NSSI NSSI Yes based on Scores on the questionnaires Cases had significantly higher (2016) [27] neuropsychiatric group: M = 15.0; group +88 in clinical data used (measuring internalizing, scores on externalizing inpatients and controls SD = 1.4; Control control group externalizing and other problems in Child Behaviour group: M = 15.4; psychological problems) were Checklist (CBCL; Z = 6.42; SD = 1.2 significantly higher among p < 0.05) and in Youth Self-

those who engaged in NSSI Report (YSR; Z = 4.57; 21 of 6 Page than in the control group. p < 0.05), than controls. Habitual self-injurers were more impulsive and alexithymic than occasional Table 1 Included relevant articles examining associations between self-injury and externalizing pathology (Continued) Meszaros

self-injurers, but they sought for help more frequently. ta.BCPsychiatry BMC al. et Guendelman USA prospective, girls with W1: M = 9.6, 140 girls with NSSI Yes interview for NSSI; Maltreated participants among There were no signifficant et al. (2016) ADHD, W1, W2 - after SD = 1.7; W2: ADHD +88 in SIQ ADHD diagnosed girls and differences in engaging in [28] 5 years, W3 - after M = 14.3; W3: comparison comparsion group were NSSI between maltreated and 10 years 19.710-year group significantly more impaired non-maltreated participants follow-up with respect to suicidal among ADHD diagnosed girls attempts, internalizing and comparsion group. Odds symptomatology eating ratio: 1.19 (CI 95%: 0.78–1.80);

disorder symptomatology, non significant (2017)17:160 and well-being than nonmaltreated participants. Guertin et al. USA cross-sectional, clinical 12–18; 95 self-mutilation Yes questionnaire for In the self-mutilative (and ODD was significantly (2001) [29] sample, inpatients after M = 15.1; self-mutilation; suicide attempt too) group, more common in the suicide attempt SD = 1.5 FASM diagnoses of ODD, MDD, self-mutilative + suicide dysthymia were more attempt group, than in the common, they also had suicide attempt only group higher scores on (X2 = 3.91; p < 0.05). hopelessness, loneliness, anger, risk taking and reckless behaviour and alcohol use scales. Hinshaw USA prospective, girls with BL: 6–12; BL: 221; self-injury Yes questionnaire Participants with childhood Self-injury is significantly et al. (2012) ADHD, matched 10 years FU: 10 years FU: for self-injury; ADHD had higher rates of more common among girls [30] controls, BL, % years FU, 17–24; 216 SIQ ADHD and comorbidity, more diagnosed with combined 10 years FU M = 19.6 serious impairment, suicide ADHD in childhood. Odds attempts and self-injury. There ratio: 4.5; p < 0.05. were no differences in eating pathology, substance use and driving behaviour. There were significant differences between inattentive and combined type only in suicide attempts and self-injury. Hurtig et al. Finland birth cohort (9479), 16–18 104 + 169 DSH Yes part of the ADHD group had both more ADHD prevalence was (2012) [31] subsample of that interviewing suicidal ideation and more significantly higher in DSH process DSH than the non-ADHD group than in no-DSH group questions group. Other factors in suicidal (69% vs. 32%, P < 0.001). for DSH behaviour: female gender, childhood emotional and behavioural problems, concurrent depression and anxiety, and especially in DSH behavioural disorder, substance use disorder and strain in family relations. –

Ilomaki et al. Finland cross-sectional, CD 12 17; 141 self-mutilation Yes part of the 40.7% of CD girls and 29.3% of Prevalence of repeated self- 21 of 7 Page (2007) [32] population: alcohol alcohol interviewing CD boys suffered from mutilation is high among CD dependents and dependent process alcohol-dependence as well. patients and higher among non-dependents girls: questions for Life-threatening suicide risk is girls. The prevalence rate M = 16.4; DSH higher among dependent girls depends on gender and boys: and boys. Self-mutilation risk is alcohol dependence of Table 1 Included relevant articles examining associations between self-injury and externalizing pathology (Continued) Meszaros

M = 16.3; also elevated in the group of participants, the lowest was non-dependent dependent girls and in the among non-alcohol- girls M = 15.3; group of dependent boys dependent boys, and the Psychiatry BMC al. et boys: as well. highest was among alcohol- M = 15.1 dependent girls. Odds ratio among girls: 3.9 (CI 95%: 1.1–13.8); Odds ratio among boys: 5.3 (CI 95%: 1.1–26.5); p < 0.05.

Izutsu et al. Japan cross-sectional, normal boys: 486 DSH Yes own Lifetime prevalence of self- ADHD scores are significantly (2017)17:160 (2006) [33] population M = 14.2; questionnaire cutting: 8.0% among boys; higher in all groups with SD = 0.7; for DSH 9.3% among girls; lifetime these problems (self-cutting, girls: prevalence of self-hitting: self-hitting, tobacco use, M = 14.2; 27.7% among boys; 12.2% alcohol use) compared to SD = 0.7 among girls. Lifetime those who do not have prevalence of tobacco use: problems in these areas 33.1% among boys, 14.3% (t = 2.55–5.56; p < 0.05). among girls; lifetime prevalence of alcohol use: 74.1% among boys; 63.4% among girls. ADHD scores are significantly higher in all groups with these problems (self-cutting, self-hitting, tobacco use, alcohol use) than those who do not have problems in these areas. Jacobson USA retrospective study, 12–19; 227 DSH, NSSI, SA Yes interview for The most frequent method of There were non-significant et al. (2008) clinical sample, M = 15.1; DSH; LPC DSH was cutting, followed by differences between the DSH [34] outpatients SD = 1.7 overdose, burning, and group and the non-DSH strangling self. 52% did not group regarding disruptive engage in self-injury, 13% behaviour disorders (X2 = 2.64; engaged in NSSI, 16% engaged p = 0.45), and significant in SA, 17% engaged in both differences in borderline- SA and NSSI. Major depressive features (X2 = 28.69; p < 0,001) disorder and/or posttraumatic stress disorder were more common in SA group, than in NSSI group. Borderline personality features were more frequent among those who engaged in any kind of DSH. The suicidal ideation levels of those in the NSSI group were similar to those in the No DSH group. Jenkins et al. USA cross-sectional, specific 18–81; 1097 NSSI Yes questionnaires Individuals with personality Individuals with personality (2015) [35] psychopatology group, M = 35.1; for NSSI; DSHI disorders, and particularly with disorders, particularly with IED patients, perosnality SD = 10.3 comorbid IED, are at increased comorbid IED are at increased 21 of 8 Page disorder, HC risk for self-injurious risk for self-injurious behaviours behaviours. Traits of aggression, (IED - control: X2 = 9.89; impulsivity and affect lability has personality disorder - control: an effect on the relationship X2 = 40.85; IED and personality Table 1 Included relevant articles examining associations between self-injury and externalizing pathology (Continued) Meszaros

between personality disorders, disorder vs. control: X2 = IED and self-injurious 94.03; p < 0.05). Traits of behaviours, especially NSSI. aggression, impulsivity and Psychiatry BMC al. et affect lability has an effect on the relationship between personality disorders, IED and self-injurious behaviours, especially NSSI. Keenan et al. USA prospective normal 13–14 years 2180 NSSI Yes part of the 6.0% of the sample engaged Higher initial levels of conduct

(2014) [36] population old girls interviewing in NSSI according to either problems (odds ratio: 1.08 (CI (2017)17:160 process child or parent report. In the 95%: 1.01–1.15); p < 0.05), questions for ‘aggression’ domain, initial lower initial levels of self- NSSI levels of conduct problems control (0.92 (CI 95%: 0.87– and self-control were 0.98); p < 0.05) and increases significantly associated with in relational aggression over NSSI. The initial levels of time (1.36 (CI 95%: 1.10–1.70); relational aggression were not p < 0.05) were associated with associated with NSSI, but the NSSI. increases in these levels over time were. In the ‘depression’ domain, initial levels of depression and a decrease in assertiveness were associated with later risk for NSSI. In the ‘environmental stressor’ domain, NSSI was associated with initial levels of peer victimization and negative life events. The most common pathway to NSSI was aggression combined with depression and environmental stressor domains, and the least common was environmental stressors only. Kirkcaldy Germany cross-sectional, clinical 3–24; 3649 SIB Yes based on clinical SIB and suicidal behaviours There was no correlation et al. (2006) sample, inpatients M = 13.4; data, regularly correlated, but aggression (or between SIB and disruptive [37] SD = 3.4 used: questionnaire disruptive behaviour) was not behaviour. for SIB, German correlated with suicide or SIB. Inventory Age and family disharmony were risk factors for suicide, but there was no association with disruptive behaviour and SIB. Intelligence and age were significant predictors of aggression among females. Lam et al. Australia cross-sectional, Range: 5–15 18.729 self-harm No based on clinical Participants from the age Compared to other causes of (2005) [14] patients owing injuries data group 11–15 years-old were injury, patients whose cause more likely to be involved in of hospital admission was 21 of 9 Page intra- and interpersonal suicide were more likely to be violence than those from the diagnosed with ADD, while age group 5–10-years-old. patients with self-harm were Female gender showed a also more likely to have Table 1 Included relevant articles examining associations between self-injury and externalizing pathology (Continued) Meszaros

stronger association with comorbid ADD as compared suicide or self-harm, while to those with other types of socioeconomically advantaged injuries (odds ratio in univariate Psychiatry BMC al. et background was related to model: 3.76 (CI 95%: 1.73–8.15); interpersonal violence. Suicide odds ratio in multivariate model: attempts and engagement in 6.27 (CI 95%: 2.76–14.26)). self-inflicted injuries were associated with staying in hospital for longer time. 3 cases resulted in death. (2017)17:160 McCloskey USA cross-sectional, adults M = 36.10; 376 SIB Yes own interview 16% reported self-aggression, 16% of IED patients reported et al. (2008) with intermittent SD = 9.32 for SIB 12.5% suicide attempts, 7.4% self-aggressive behaviour, with [38] explosive disorder non-lethal self-injurious 12.5% attempting suicide and behaviours. MDD, drug 7.4% engaging in SIB. This dependence and Axis-I shows a relationship between comorbidities all predicted SA IED and self-aggression. or SIB in IED. Women were at increased risk for self-aggressive behaviour overall, but it was not significant for either SA or SIB. Meza et al. USA prospective, patients W1, M = 9.6, 228 with NSSI Yes interview for NSSI; Wave 1 commission errors There were a significant (2016) [39] (girls) with ADHD and range6–12); (n = 140) and SIQ (indicator of response differences in NSSI severity control group 5 years without inhibition) predicted Wave 3 between ADHD group and follow-up (n = 88) suicide ideation with marginal comparsion group (Cohen’sd: (W2, M = 14.2, childhood significance and significantly 0.60; p < 0.001). Childhood range 11–18); ADHD predicted suicide attempts response inhibition predicted 10-year and NSSI severity. Social NSSI in young adulthood in follow-up preference was a significant longitudinal study (B = 0,16; (W3, M = 19.6, partial mediator of the Wave 1 p < 0,05; R2 = 0.03). range 17–24) commission errors and suicide ideation: indirect effect. Wave 2 peer victimization was a significant partial mediator in the Wave 1 commissions and Wave 3 NSSI severity. Nock et al. USA cross-sectional, case 12–17 (M = 14,7) 89 NSSI, SIB Yes questionnaire 87.6% met at least one Axis I Some sort of externalizing (2006) [40] series, inpatient unit for self- criterion, internalization 51.7%, disorder was present in 62.9% patients who engaged mutilation; externalization 62.9%, of the NSSI sample (CD: 49.4%; in NSSI FASM substance use 59.6%; 67.3% of ODD: 44.9%). Substance use female patients met Axis II disorder was present in 59.6%, criteria (51.7% BPD was the while some sort of most common). 70% reported internalizing disorder was at least one suicide attempt, present in 51.7%. 55% reported more than one suicide attempt. Preyde et al. Canada prospective, clinical 5–18; 210 (Self-harm NSSI, self-harm Yes part of the 39% who reported self-harm Higher symptom severity (2012) [41] population M = 11.57 data available interviewing at admission were less than among self-harmers compared ae1 f21 of 10 Page (SD = 2.75). for 169) process 12 years of age. Most of the to non-self-harmers on questions for differences between self- Attention and Impulsivity self-harm; harmers and non-self-harmers regulation and Total Mental BCFPI on symptom severity at intake Health was measured. Mean disappeared by the time of scores (SD; CI 95%) on Table 1 Included relevant articles examining associations between self-injury and externalizing pathology (Continued) Meszaros

follow up. Youth who Attention and Impulsivity engaged in self-harm had regulation: no self-harm: higher symptom severity on 70.9 (10.2; 68.8–73.0); self Psychiatry BMC al. et Attention and Impulsivity harm: 75.3 (7.8; 73.0–77.5); regulation, Managing Mood, mean scores (SD; CI 95%) on Internalizing Behaviour and Total Mental Health: no Total Mental Health. At self-harm: 77.4 (11.4; 75.1– discharge, symptom severity 79.8); self harm: 82.5 (11.1; only differed on the Total 79.2–85.9); p < 0.05. Mental Health subscale, and no differences were evident at (2017)17:160 12 to 18 months post- discharge or 36 to 40 months post-discharge. Semiz et al. Turkey cross-sectional, male 20–36; 105 SIB Yes own interview 92% reported SIB with 57% The number of ADHD (2008) [42] offenders in psychiatry M = 22.7; for SIB reporting more than 10 symptoms was significantly department of a military SD = 2.9 episodes. The onset of SIB was correlated with frequency of between 5 and 23 years with SIB (correlation coefficient: mean onset at 14.8 years, and 0.32; p < 0.05). ADHD total the mean duration of the score was significantly behaviour was 7.2 years. 65% correlated with frequency of had received medical SIB (correlation coefficient: treatment for their SIB. APD 0.38; p < 0.05) and negatively participants who had correlated with age of onset comorbid ADHD did report a of SIB (correlation coefficient: significant increase in suicide −0.23; p < 0.05). attempts but not in SIB or criminal behaviours. The number of ADHD symptoms was significantly correlated with frequency of SIB. ADHD total score was significantly correlated with frequency of SIB and negatively correlated with age at onset of SIB. Swanson USA prospective, patients 6–12; M = 9.1 140 girls with NSSI Yes interview for Combined type of ADHD There were significant et al. (2014) (girls) with ADHD ADHD +88 in NSSI; SIQ engaged in the most severe differences in NSSI frequency, [43] and control group comparison forms of NSSI using the most variety and severity between group methods compared to combined ADHD and childhood-diagnosed comparsion groups inattentive type of ADHD (inattentive ADHD and and comparison groups. Both control; Cohen’s d: 0.20–0.85; ADHD subtypes showed p < 0.05). Persistent ADHD increased NSSI frequency also differed significantly from compared to the comparison comparsion groups (transient group but did not significantly ADHD and control) in NSSI differ from each other. frequency, variety and severity Persistent ADHD showed (Cohen’s d: 0.32–0.87; increased NSSI compared to p < 0.05). Externalizing 21 of 11 Page those with transient ADHD or symptoms mediate between the comparison group. ADHD and NSSI (IE = 0.29; Participants with persistent SE = 0.11; CI 95%: 0.10–0.51). ADHD also had a higher rate Table 1 Included relevant articles examining associations between self-injury and externalizing pathology (Continued) Meszaros

of suicide attempts. Externalizing symptoms and a lab-based measure of Psychiatry BMC al. et response inhibition/impulsivity were significant partial mediators between ADHD and NSSI while internalizing symptoms during adolescence was a significant partial mediator of the ADHD-suicide attempt linkage. (2017)17:160 Taylor et al. New- case–control study, M = 31.9; 66 (35 with DSH Yes questionnaire Significant associations were Significant associations were (2014) [44] Zealand patients with SD = 1.6 adult ADHD for DSH; DSHI present between ADHD present between ADHD retrospective ADHD and 31 with symptom severity and history symptom severity and history and control group no ADHD) of self-harm behaviour, of self-harm behaviour suicidal ideation and suicide (B = 0.52; SE = 0.24; p < 0.05). attempts. These relationships These relationships were were mediated by mediated by comorbidity comorbidity (mood, anxiety, (B = 0.68; SE = 0.23; p < 0.01) drug and alcohol abuse and emotion-focused coping disorders) and emotion- style (B = 0.72; SE = 0.22; focused coping style. The p < 0.01). results suggest that comorbid mental health disorders and emotion-focused coping might mediate the relationship between self- injurious behaviour and ADHD. Vaughn et al. USA prospective, 18–49 19.073 DSH No part of the DSH was linked to ethnicity Besides DSH being linked to (2015) [15] normal population interviewing since African-American, substance abuse (odds ratios: process questions Latinos and Asians were less 2.90–7.02), it was also for self-harm likely to report DSH than associated with violent Whites. DSH was associated behaviours such as robbery, with all forms of child intimate partner violence, maltreatment: child sexual forced sex, cruelty to animals abuse, physical abuse, child and use of a weapon (odds neglect and exposure to ratios: 3.32–12.73). serious conflict in the home. DSH was also associated with lifetime victimization: intimate partner violence, violent victimization, and to ever having been stalked. DSH was also associated with MDD, avoidant personality disorder and schizotypal personality disorder. DSH was also 21 of 12 Page related to engaging in violent behaviours, particularly robust effects were shown with “having forced someone Table 1 Included relevant articles examining associations between self-injury and externalizing pathology (Continued) Meszaros

to have sex with you against their will”. ta.BCPsychiatry BMC al. et You et al. Hong cross-sectional, 11–19; 6374 NSSI Yes part of a Repetitive self-injurers had There was a strong link (2011) [45] Kong normal population M = 14.7; longer more impulse-control and between NSSI frequency SD = 1.9 questionnaire, emotional problems, than (odds ratio: 1.37 (CI 95%: 1.32– questions for episodic self-injurers. Severe 1.42); p < 0.01) and severity NSSI self-injurers were more (1.12 (CI 95%: 1.08–1.17); impulsive than mild self- p < 0.01) and impulse control injurers. The frequency and problems.

severity of NSSI are two (2017)17:160 possible dimensions that distinguish NSSI subgroups. Young et al. UK cross-sectional, M = 30.0; 198 critical incident, No based on 24% of prisoners met ADHD (2009) [16] prisoner population SD = 8.2 self-injury institutional criteria in the present or in the The mean number of critical data past. 23% of them were fully incidents was significantly symptomatic, 33% were in higher in the ADHD group partial remission and 44% than in the non-ADHD group were in full remission. Critical (F = 5.01; p < 0.001). incidents (verbal and physical aggression, damage to property, self-injury, and severity of aggression) were more common among the ADHD group than in the non-ADHD group, the most severe forms found among fully symptomatic ADHD group. Zlotnick et al. USA cross-sectional, M = 40.6; 256 self-mutilation No own From the Axis-I disorders, sub Self-mutilation was associated (1999) [17] psychiatric outpatients SD = 14.0 questionnaire stance abuse, posttraumatic with substance abuse for self- stress disorder and IED (X2 = 13.73; p < 0.05), IED mutilation showed significant association (X2 = 6.35; p < 0.05) and to self-mutilative behaviour, antisocial personality disorder independent of BPD and anti (X2 = 8.03; p < 0.05). social personality disorder. Moreover, higher scores of dissociation were associated with self-mutilation while controlling for age, BPD, sex, education, sexual abuse and physical abuse. ae1 f21 of 13 Page Meszaros et al. BMC Psychiatry (2017) 17:160 Page 14 of 21

pre-ejection period; RSA: respiratory sinus arrhythmia; SA: ‘critical-incidents’ that they defined as auto or hetero- suicide attempt; SIB: self injurious behviour; SII: self aggressive acts in an incarcerated population. inflicted injury; SIQ: The suicidal ideation questionnaire; There were some other phrases describing self-injurious SITBI: Self-Injurious Thoughts and Behaviors Interview. behaviour: ‘parasuicide’ [13]: there is no distinction be- tween suicidal-nonsuicidal intent; ‘self-inflicted injury’ (SII) [21]: this is a nonsuicidal act; ‘suicide gesture’ [26]: Terms and definitions for self-injurious behaviours in the this is a nonsuicidal self-injury or a suicidal attempt to included studies communicate with others. Below, the different terms and their presence in the reviewed publications are displayed. It is important to Measurements of self-injurious behaviours in the included clarify that in general the term ‘self-injurious behaviours’ studies is used for describing all of these acts, which are not the Among the studies included in our review, diagnostic in- same as the specific term ‘self-injurious behaviour (SIB)’. terviews, self-reported questionnaires and institutional In 7 papers there was no clear distinction between the records were used to measure self-injurious behaviours: purpose of the investigated self-injurious act (whether it altogether we found 20 different instruments among the was with suicidal intent or not) [11–17], but in the investigated 35 papers. remaining 28 papers the defined self-injurious behaviour In 9 cases, the authors designed a longer diagnostic was a nonsuicidal act [18–45]. interview, and some questions about self-injurious behav- There were 11 different terms for self-injurious behav- iours were included in it [11, 15, 18, 19, 22, 31, 32, 36, 41]. iour in the investigated 35 papers. An interview specially developed for measuring self- ‘NSSI’ was the most common term: this expression was injurious behaviours was used in 10 studies [13, 21, 26, 28, presented in 10 studies [27, 28, 34–36, 39–41, 43, 45]. In 30, 34, 38, 39, 42, 43]. The Self-Injurious Thoughts and accordance with the term itself this expression was used Behaviors Interview (SITBI) [46] was applied by Garcia- only in nonsuicidal meaning. Six studies used only this Nieto et al. [26]. The Lifetime Parasuicide Count (LPC) term for describing the behaviour [27, 35, 36, 39, 43, 45]. [47] was used by Jacobson et al. [34], Crowell et al. In other studies, NSSI could be found as a part of wider [13], Crowell et al. [21]. However, in the study of Cro- self-injurious behaviours: Jacobson et al. [34] use ‘deliber- well et al. [21], it was mentioned under a different ate self-harm’ (DSH), Nock et al. [40] use ‘self-injurious name: Lifetime-Suicide Attempt Self-Injury (L-SASI). behaviour’ (SIB), Preyde et al. [41] and Guendelman et al. An interviewer-administered modification of the Self- [28] use ‘self-harm’ for describing both suicidal and non- Injurious Questionnaire (SIQ) [48] appeared in the suicidal self-injurious behaviours. Darke and Torok [22] studies of Guendelman et al. [28], Hinshaw et al. [30], used ‘non-suicidal self-harm’ as a term, but their definition Meza et al. [39] and Swanson et al. [43], however these 4 was similar to other NSSI definitions. papers are based on the same population. Both McCloskey ‘DSH’ was presented in 6 publications [15, 20, 31, 33, et al. [38] and Semiz et al. [42] developed their own inter- 34, 44]. Four studies used it in a nonsuicidal meaning view as an instrument for measuring self-injurious [20, 31, 33, 44], however, 2 studies [15, 34] did not make behaviours. this distinction. Five papers [15, 20, 31, 33, 44] defined Self-report questionnaires were used for measuring ‘DSH’ as physical self-injurious behaviour, although self-injurious behaviours in 9 studies [17, 20, 23, 29, 33, Jacobson et al. [34] defined it as a possible overdose act 35, 40, 44, 45] in all. Two papers contained question(s) as well. Both Aglan et al. [11] and Chou et al. [12] used about self-injurious behaviours as a part of a longer the term ‘deliberate self-poisoning’ (DSP), which they questionnaire [23, 45]. Individual questionnaires as an originated from DSH, but only in the meaning of an instrument for the measurement of self-injurious be- overdose, they did not make the suicidal-nonsuicidal haviours can be found in 7 publications [17, 20, 29, 33, distinction. 35, 40, 44]. The Deliberate Self-Harm Inventory (DSHI) ‘Self-mutilation’ was found in 5 publications [17, 19, [49] appears in 3 studies [20, 35, 44]. The Functional 25, 29, 32]. The term is used for nonsuicidal physical Assessment of Self-Mutilation (FASM) [50] was used in self-injurious behaviours, except for Zlotnick et al. [17], 2 studies [29, 40]; the original questionnaire form of who did not distinguish the purpose of the act. SIQ [51] was not applied by any of the investigated ‘SIB’ was a term in 4 papers [37, 38, 40, 42], it is also papers. Own developed questionnaire was used in 2 mainly used in a nonsuicidal meaning, except for Nock papers [17, 33]. et al. [40]. In the remaining 7 publications, some kind of institu- ‘Self-injury’ was presented in 4 papers [18, 24, 30, 45], tional (health care, prison) records or national databases and ‘self-harm’ was found in 3 studies [14, 23, 41]. were the sources of the data on self-injurious behaviours Young et al. [16] used ‘self-injury’ as a subgroup of [12, 14, 16, 24, 25, 27, 37]. It is important to highlight Meszaros et al. BMC Psychiatry (2017) 17:160 Page 15 of 21

the work of Kirkcaldy et al. [37]: although they based [38] found the prevalence of SIB to be 16% in this group. their examinations on the health records of German ad- Jenkins et al. [35] investigated participants with person- olescents and youths, in the region where their study ality disorder with or without IED: they found the preva- was conducted, the German Inventory Questionnaire – lence of NSSI to be 18%. which contains questions about SIB – is a regular part Only in one publication could data be found on the of the documentation. prevalence of self-mutilation among participants with conduct disorder (CD) [32]: they found its prevalence Prevalence of self-injurious behaviour between 15.5 and 62.5%. It depends on the gender and Epidemiological data about self-injurious behaviours in alcohol dependence of participants, with the lowest different groups can be found in 20 publications (see de- prevalence being among non-alcohol-dependent boys, tails below). and the highest being among alcohol-dependent girls. Six studies examined the normal population [15, 20, However there was another study, which examined the 23, 33, 36, 45]. Among them 3 papers used the term prevalence of SIB among psychiatric offenders in a mili- DSH and found the prevalence rates between 2.9 and tary institution with antisocial personality disorder [42]: 41.9% [15, 20, 33]. NSSI was a term in 2 publications: the prevalence rate of SIB was 92.0%. with prevalence rates of 6% [36] and 15% [45]. Evren et al. [23] used the term ‘self-harm’, and found its preva- Correlations of self-injurious behaviours and externalizing lence to be 14.3%. psychopathology Five studies investigated general psychiatric popula- Fifteen publications investigated the associations be- tions (inpatients, outpatients or intensive home-based tween self-injurious behaviours and ADHD [12, 14, 16, treatment population) [17, 24, 34, 37, 41]. Among them 18, 21, 23, 25, 28, 30, 31, 33, 41–44]. Four of them only one paper used NSSI as a term: Jacobson et al. [34], studied ADHD versus non-ADHD groups, and found however they also used DSH to include suicidal behav- robust differences in the prevalence or incidence rates iour, and they found 13% prevalence of NSSI and 17% of of self-injurious behaviours (self-injury [18, 30]; DSH DSH. Feingold et al. [24] investigated ‘self-injury’, and [31]; DSP [12]). Higher symptom severity or higher found its prevalence to be 32.4%. Kirkcaldy et al. [37] ex- scores on ADHD symptom scales or higher numbers of amined SIB with a prevalence rate of 59%. Preyde et al. ADHD symptoms are associated with self-injurious [41] studied ‘self-harm’ and found 34% as its prevalence behaviour in 6 papers: ADHD scores were higher in the rate. ‘Self-mutilation’ was the term in the study of Zlot- SII group than in the control group or depressed group nick et al. [17], and the prevalence rate was 33.2%. [21]; ADHD scores were higher in the self-harm group In the study of Carli et al. [19] there was an incarcer- versus non-self-harm group [23]; and in the DSH group ated population. They found the prevalence of ‘self-mu- versus non-DSH group [33]; frequency of SIB was tilation’ to be 17.0%. correlated with the number of ADHD symptoms [42]; In the remaining 8 studies, the aim of the investigation those who engaged in self-harm in a residential treat- was to compare a group having a specific psychopath- ment or intensive home-based treatment programme ology with a healthy control group or with a group hav- had higher ADHD symptom severity than those who ing another psychopathology. did not engage in this behaviour [41]; and there was a Four publications examined attention deficit hyper- significant association between symptom severity of activity disorder (ADHD) as a group with specific psy- ADHD and history of DSH behaviours [44]. Moreover, chopathology [12, 18, 30, 31]. Among ADHD patients Fulwiler et al. [25] found the importance of childhood versus non-ADHD patients, there was a robust differ- ADHD in adulthood self-mutilation among prisoners. ence in the prevalence rates of self-injurious behaviours. Lam et al. [14] underline that the odds ratio of having Prevalence of self-injury was 50.6% in the combined type comorbid attention deficit disorder (ADD) is 3 times of ADHD, versus 28.9% in the inattentive type of ADHD, higher in the self-harm group than in the non-self- versus 19% in the non-ADHD control group [30]. Preva- harm group. Swanson et al. [43] found that both the lence of self-injury among drug dependent patients with inattentive and combined type of ADHD were associ- ADHD was 47.7%, versus 25.2% without ADHD [18]. ated with NSSI, however more severe forms and higher Prevalence of DSH was 69% in an ADHD group and frequency of NSSI are more likely to be associated with 32% in a control group [31]. In one study there was a the combined type. Young et al. [16] emphasize that significant difference in the incidence of DSP: it was the number of critical incidents (including self-injury) 6.13/10,000 persons/years in the ADHD group and 1.36/ were higher among people with ADHD in an incarcer- 10,000 persons/years in the control group [12]. ated population. According to the work of Guendelman Two studies examined intermittent explosive disorder et al. [28], maltreatment is a strong risk factor of both (IED) as a specific psychopathology. McCloskey et al. NSSI and any other self-harm acts (suicide attempts), Meszaros et al. BMC Psychiatry (2017) 17:160 Page 16 of 21

and there is no significant difference in this risk effect depressed groups. In the 100% NSSI sample of Nock et between girls diagnosed with ADHD and comparison al. [40] the presence of any externalizing disorder was group. 62.9% while the presence of any internalizing disorder Twelve publications examined the possible connection was 51.7%. Feingold et al. [24] did not study the direct between conduct disorder (CD) or CD symptoms or link between externalizing pathology and self-injury, but antisocial personality disorder in adulthood and self- they found a strong link between alcohol abuse and self- injurious behaviours [11, 15, 20–22, 26, 32, 34, 36, 37, injury, and also described the association between exter- 40, 42]. Seven of them found significant positive nalizing pathology and alcohol abuse. Gatta et al. [27] associations: CD is a risk factor of adulthood DSP repeti- examined neuropsychiatric inpatients who engaged in tion [11]; both CD and oppositional defiant disorder NSSI and controls from high schools. They found sig- (ODD) correlated with DSH, however there is no signifi- nificantly higher externalizing scores in the NSSI group cant difference in the level of correlation between them than in the control group according to both self-report [20]; there were higher CD scores in the SII group than and parent-report. in the control group or depressed group [21]; antisocial In the remaining 3 studies, the authors examined traits personality disorder is a risk factor of suicidal gestures of externalizing psychopathology: Carli et al. [19] found (included self-injurious behaviour) [26]; prevalence of a significant difference in the prevalence of self- self-mutilation is high among CD patients, especially mutilation between high-impulsive and low-impulsive when they are girls and they are also alcohol-dependent groups. You et al. [45] investigated the role of impulse- [32]; higher initial levels of conduct problems are associ- control problems in the frequency and severity of NSSI ated with NSSI [36]; and DSH is linked to violent behav- and found individuals with more impulse-control prob- iours (robbery, intimate partner violence, forced sex, lems had more severe and frequent NSSI behaviour. cruelty to animals, use of a weapon) [15]. Two publica- Meza et al. [39] found the importance of response inhib- tions described a non-significant positive connection: CD ition in the prediction of NSSI among individuals with symptoms are more frequent in a non-suicidal self-harm or without ADHD. group than in the control group [22]; frequency of any disruptive behaviours was higher both in DSH and in Self-injury and suicide NSSI groups than in the control group [34]. Nock et al. In total 8 of the 35 articles assessed the relationship be- [40] found the presence of CD to be 49.4% in their 100% tween self-injury and suicide [22, 25, 26, 29, 31, 32, 34, 43]. NSSI sample. Semiz et al. [42] found the prevalence of SIB To compare results by age groups, we will first over- to be 92% in a 100% antisocial personality disorder sam- view 3 papers that studied adult samples [22, 25, 26] ple. However Kirkcaldy et al. [37] could not find any asso- and then turn to the other 4 studies that assessed ado- ciation between SIB and disruptive behaviour. lescence populations [29, 31, 32, 34] and one longitu- Four papers studied the link between oppositional defi- dinal study that assessed young girls (M = 9.1 years) ant disorder (ODD) and self-injurious behaviours or SIB. with 5 and 10 years follow-ups [43]. Cerutti et al. [20] found, that ODD correlated with DSH In their study on adult injecting drug users, Darke and but they did not find a significant difference with the cor- Torok [22] assessed if the two phenomena (NSSI and relation of CD and DSH. In the study of Crowell et al. suicidality) overlap. They found that 42.3% of those who [21], there are higher ODD scores in the SII group than in reported NSSI also reported suicide attempt, and 39% of the depressed group or control group. Guertin et al. [29] those who reported suicide attempt had also engaged in found that ODD was more common in both the self- NSSI. In 83.3% of the cases with both suicidal and NSSI, mutilator and suicide attempter group than in the suicide the NSSI was present prior to suicide attempts. attempter only group. In Nock et al. [40], in the 100% The other two studies on adult samples focused on NSSI sample the presence of ODD was 44.9%. the differences between suicidal and NSSI behaviours There are 3 publications that strengthen the relationship [25, 26]. between intermittent explosive disorder and self-injurious In an adult prisoner sample, Fulwiler et al. [25] found behaviours (NSSI [35]; SIB [38]; self-mutilation [17]). differences between those committing suicide attempts There was information about general externalizing and self-mutilation regarding their methods (more le- symptoms in 5 publications. Crowell et al. [13] examined thal methods in suicide attempt) and frequency (higher parasuicidal versus non-parasuicidal groups; in the para- frequencyincaseofself-mutilation).Thetwogroups suicidal group the T-scores of externalizing symptoms also differed in psychiatric comorbidities: diagnosis of were significantly higher. Crowell et al. [21] investigated an affective disorder was present in 87% of the suicide the SII group, control group and depressed group: T- attempt group compared to 19% in self-mutilators, scores of externalizing psychopathology were also sig- while a syndrome of mixed anxiety/dysthymia patterns nificantly higher in the SII group than in the control or present from childhood or adolescence (56% in self- Meszaros et al. BMC Psychiatry (2017) 17:160 Page 17 of 21

mutilation group) and history of childhood hyperactiv- controlling for gender, participants in the suicide at- ity (75% vs 7%) characterized the self-mutilation group. tempt only group (OR = 8.93; 95% CI = 1.04–76.92; Garcia-Nieto et al. [26] also focused on the differ- p = 0.046) and the suicide attempt and NSSI group ences between self-injurers with and without intent to (OR = 10.09; 95% CI = 1.18–85.97; p = 0.035) were die. Their results pointed out the differences in the more likely to have PTSD diagnosis than those in the prevalence of certain personality disorders: histrionic NSSI-only group. The NSSI-only group also reported personality disorder (HPD) (0% in neither gestures nor significantly lower levels of suicidal ideation scores than attempts; 46.7% in gestures; 1.6% in attempt, 12.5% in the other DSH groups: Suicide attempt only (adjusted attempts + gestures group) and antisocial personality mean difference = −20.24, p < 0.001) and suicide at- disorder (APD) (5.3% in neither gestures nor attempts; tempt and NSSI group (adjusted mean differ- 6.7% in gestures; 4.8% in attempt, 1.2% in attempts + ence = −25.92; p < 0.001). Meanwhile the two other gestures group) as risk factors were associated with DSH groups (suicide attempt only and suicide attempt suicide gestures. Narcissistic personality disorder and NSSI groups) did not significantly differ from each (NPD) (27% in suicide attempt group, 0% in all other other regarding the rates of MDD, PTSD and the levels groups) showed association with suicide attempts, and of suicidal ideation. BPD (7% in neither gestures nor attempts; 33.3% in Swanson et al. [43] studied girls recruited from both gestures, 9.7% in attempts, 43.8% in gesture + attempt a clinical and non-clinical background in their follow- group) seemed to be a risk factor for both suicide ges- up study (age at baseline: M = 9.1 years; age at Wave 2: tures and attempts. M = 14.2 years; age at Wave 3: M = 19.6 years). Ac- In an adolescent community sample [31], those with cording to their findings, externalizing symptoms and ADHD reported more suicidal ideation (57% vs. 28%, inhibition/impulsivity might be significant partial medi- P < 0.001) and DSH (69% vs. 32%, P < 0.001) than those ators between Wave1 ADHD and W3 NSSI scores (in- who did not have the disorder. Female gender and de- direct effect – IE = 0.29; standard error – SE = 0.11; pression/anxiety were also associated with both suicidal CI95 = 0.10–0.51); while Wave 2 internalizing symp- ideation and DSH, while behavioural disorder, sub- toms might be a significant partial mediator of the stance use and certain family factors (e.g. living in non- Wave 1 ADHD Wave 2 suicide attempt linkage intact family, living in family with financial problems) (IE = 0.11; SE = 0.05; CI95 = 0.03–0.25). were associated with DSH but not with suicidal idea- Ilomaki et al. [32] did not investigate the associ- tion and acts. ation between the two phenomena but they found In an adolescent inpatient sample, those who not only that alcohol dependence was a common potential risk had a history of suicide attempt but also a history of self- factor for both phenomena since it increased the risk mutilative behaviour were significantly more likely to have for both suicide attempts 3.8-fold [CI95 = 1.06–13.44; adiagnosisofODD(χ21(N =75)=3.91,p < .05); major p = 0.041] and self-mutilation 3.9-fold (CI95 = 1.09– depressive disorder (MDD; χ21(N = 76) = 13.74, p < .01;) 13.76; p = 0.037) among adolescent girls with DSM- and dysthymia (χ21 (N =76)=4.82,p < 0.05), and had IV-diagnosed CD. higher scores of loneliness (F = 8.24, p <0.05),anger (F = 11.88, p < 0.05), risk taking (F = 16.31, p < 0.05) and Discussion reckless behaviour (F = 7.21, p ≤ 0.005) [29]. In the current systematic review, 35 papers examining Jacobson et al. [34] studied an adolescent outpatients the correlation between externalizing psychopathology sample with no DSH (52%), NSSI only (13%), suicide and self-injurious behaviours are summarized. attempt only (16%) and with both NSSI and suicide at- Consistent with the review on internalizing pathology tempt (17%). They found that the only psychiatric diag- andNSSI[7],wefoundwide-rangingterminologyfor nosis in which those engaging in NSSI differed from self-injury: 11 different terms were used in 35 papers. those who had not engaged in any type of DSH was Among these terms NSSI has the clearest definition, BPD. When distinguishing between DSH groups, differ- suggested by the ‘International Society for the Study of ences were found in the likeliness of comorbid depres- Self-injury’ (ISSS) in 2007 [2] and by DSM-5 [1]. DSH sion, posttraumatic stress disorder (PTSD) and in the is the most unstable term, because it has many defini- levels of suicidal ideation. Regarding MDD, with the tions, some authors use it only in a nonsuicidal mean- NSSI only group as the comparison group and control- ing [20, 31, 33, 44], while others use it as non-fatal but ling for gender, the suicide attempt only group (odds with both suicidal and nonsuicidal meanings [15, 34]. ratio – OR =3.43; 95% CI = 1.17–10.00; p =0.03)and The other issue is that self-poisoning was not included the suicide attempt and NSSI group (OR = 3.55; 95% in the definition by most of the authors [15, 20, 31, 33, confidence interval – CI = 1.24–10.16; p = 0.02) were 44], but Jacobson et al. [34] use the term DSH both for more likely to have depression. Regarding PTSD, when physical self-damage and overdose cases as well. Meszaros et al. BMC Psychiatry (2017) 17:160 Page 18 of 21

Moreover, DSP appeared as an individual term for self- There were significantly higher prevalence rates in poisoners [11, 12]. SIB is mostly defined as both suicidal ADHD groups than in control groups [12, 18, 30, 31]. and non-suicidal self-injurious behaviour, but self- Moreover, the papers found higher ADHD symptom poisoning is not included in the definition [37, 38, 40, 42]. severity in self-injurer groups [21, 23, 33, 41, 42, 44]. Summarizing the main issues of defining self-injurious be- The most severe and frequent forms of NSSI can be haviour are the following: whether the definition used found in the combined types of ADHD versus the in- should include self-poisoning or not, and whether it attentive type and the control group [43], that should be clarified as a suicidal or a nonsuicidal act. For strengthen the role of impulsivity in self-injurious be- example, Kapur et al. [52] questioned the concept of NSSI, haviours, which is an important risk factor of self- because in some cases it is impossible to decide if the act injurious behaviours. However, according to Hamza et was with suicidal intent or not, especially in an adolescent al. [54], itis very complicated to measure, especially population. Nock [53] drew attention to this definition with self-reported questionnaires. Moreover, it seems problem in his earlier review; while sometimes those who that different aspects of impulsivity have different roles have engaged in self-injury cannot themselves clarify their on self-injury. Mood-based impulsivity influences the intent, conceptually it is important to make this distinc- initiation of self-injury, cognitive facets of impulsivity tion. Brunner, Kaess et al. [10] made the distinction be- are related to the maintenance of self-injury and behav- tween self-poisoning and self-harming by focusing on the ioural impulsivity is associated with self-injury under surface of the body. conditions of negative affect [55]. The heterogeneity that is present in the terminology In addition to the finding that ADHD and self- and definitions of self-injurious behaviours is also injurious behaviours are strongly associated, which is in reflected in the diversity of instruments used to assess agreement with a previous review on this topic [8], we the phenomenon. The most frequently used instru- found evidences for the association between self- ments (LPC [13, 21, 34]; DSHI [20, 35, 44]) were injurious behaviours and other externalizing psychopath- present in no more than three plus three out of the 35 ology. There are high prevalence rates of self-injurious studies. Among the studies included in our review, behaviours among patients with CD (15.5–62.5%, it de- diagnostic interviews, self-reported questionnaires, in- pends on the gender and alcohol dependence of partici- stitutional (health care, prison) records and national da- pants [32]. Semiz et al. [42] found the prevalence rate of tabases were used to measure self-injury. In more than SIB to be 92.0% among male offenders with antisocial half of the papers (18/35) the method was an interview, personality disorder. Moreover, there were higher CD or special questions as part of a longer interview [11, 13, scores in the self-injurer group, than in the control 15, 18, 19, 21, 22, 26, 28, 31, 32, 34, 36, 38, 39, 41–43]. group [21]; and in 6 further studies there are strong The instruments were based on the previously de- links between CD or disruptive symptoms and self- scribed different definitions of self-injury and there- injurious behaviours [11, 15, 20, 26, 32, 36]. Only one fore they may measure somewhat different paper from the 12 investigated could not find a link be- phenomena. This may be one of the factors that tween CD and self-injury [37]. The relationship between make it difficult to compare the results of different self-injurious behaviours and ODD is underlined by 3 studies, as we have already highlighted above. papers [20, 21, 29], and there is a connection with inter- The prevalence rates of different self-injurious mittent explosive disorder as well according to 3 studies behaviours vary greatly both in clinical samples (13.0– [17, 35, 38]. General externalizing symptoms are also 59.0%) and in normal population based samples (2.9– more frequent in self-injurer groups [13, 21]. Nock et al. 41.9%). This variance can be explained partially by the [40] found higher externalizing comorbidity than intern- definition and measurement heterogeneity, described alizing in self-injurer groups. above. However, using one term (e.g. NSSI) does not Although the aim of this review was not specifically lead to more homogenous prevalence rates. In the spe- to explore the relationship between NSSI and suicid- cific psychopathology groups investigated, the diver- ality, 8 out of the 35 articles contained results regard- sity of prevalence rates could also be observed. Due to ing this topic. Although the two phenomena might this heterogeneity, and with the aim of avoiding confu- overlap [22, 34] and might have shared clinical char- sion, the original terms used by the authors of the acteristics such as BPD [26], depression and anxiety papers are used in the ‘Results’ section, and the preva- [31] or alcohol dependence [32], most of these arti- lence rates are mentioned in parallel. These various cles focused on factors distinguishing between suicide results underline the importance of standardized and NSSI. Those with and without suicidal intent terminology and measurement for self-injurious be- might show differences in the frequency and methods haviours, which would make the results of future stud- of their self-injuring, comorbid symptoms and person- ies comparable. ality disorders [25, 26]. Some results show that while Meszaros et al. BMC Psychiatry (2017) 17:160 Page 19 of 21

externalizing symptoms are associated with NSSI [25, 43], NSSI and externalizing pathology, the role of externaliz- internalizing symptoms might play a bigger role in sui- ing problems in the relationship between NSSI and sui- cidality [25, 34, 43]; while others found higher numbers cidality might be overrepresented, while other important of both internalizing and externalizing symptoms factors might remain hidden. A review focusing directly among those who reported both suicidal behaviour and on the NSSI-suicidality relationship, including two of the NSSI [29, 31]. articles discussed in this paper [29, 34] was just recently published [56]. According to their conclusion, the two Limitations phenomena are correlated and share similar vulnerabil- The main limitation of our review is the heterogeneity ities and risk factors, moreover, NSSI itself is found to of both the terminology and instruments, as we men- be a risk factor for suicidal behaviour. tioned above, which makes it hard to compare the re- sults of the included papers. In most of the cases, the Conclusions distinction that the act was with or without suicidal In conclusion, reviewing these 35 papers on self-injury intent was clear, however, among these 35 papers there and externalizing psychopathology underlines the confu- were 7 papers, where this distinction was not clarified sion in terminology on self-injurious behaviours, which – [11 17]. The fact that similar terms for self-injurious could lead to difficulty in comparing studies on the behaviour were also measured with multiple instru- topic. Based on our findings, we suggest the use of the ments in different studies also complicates the under- term NSSI in future studies, as NSSI has the most pre- standing of the topic. cise definition. Furthermore, it became an individual A further limitation is that we may be missing some diagnostic category in DSM-5 [1]. relevant papers on this topic. Firstly, because we in- Summarizing the results of these papers – although cluded only articles that are written in English. Sec- the connection between internalizing pathology and self- ondly, we have chosen the standard method and injurious behaviours are well-studied [7] – there is a searched for publications in large indexed literature strong association between self-injurious behaviours and databases. This led to 14 papers on the topic of ADHD externalizing pathology and individual externalizing dis- and self-injury, however, Allely [8] used a less conser- orders as well. Based on this knowledge, it seems to be ‘ ’ vative search method and checked Google Scholar as important to investigate the presence of parallel internal- well and found 15 articles on the topic of ADHD and izing and externalizing pathology and its connection to NSSI, which is a sub-topic of our review topic. There NSSI, because it may help to identify the most endan- were small differences in our keywords as well, that gered populations. could also be an explanation for the differences in our findings. They used ‘self-poisoning’ as a search word Abbreviations as well. Finally there were 5 overlapping publications ADHD: Attention deficit hyperactivity disorder; APD: Antisocial personality disorder; BPD: Borderline personality disorder; CD: Conduct disorder; [25, 30, 31, 33, 42], but they found 9 publications that CI: Confidential interval; DSH: Deliberate self-harm; DSHI: Deliberate Self-Harm we did not (5 of them fit our inclusion criteria as well, Inventory; DSM: Diagnostic and Statistical Manual of Mental Disorders; buttheyhadnotappearedinoursearch)andwe DSP: Deliberate self-poisoning; FASM: Functional Assessment of Self- Mutilation; HPD: Histrionic personality disorder; IE: Indirect effect; found 3 articles in their time window, that they had IED: Intermittent explosive disorder; ISSS: International Society for the Study not [18, 21, 41]. The remaining 5 publications we of Self-injury; LPC: Lifetime Parasuicide Count; L-SASI: Lifetime-Suicide found miss their time window [12, 14, 23, 43, 44]. In Attempt Self-Injury; MDD: Major depressive disorder; NPD: Narcissistic personality disorder; NSSI: Nonsuicidal self-injury; ODD: Oppositional defiant spite of all these differences in the papers, Allely [8] disorder; OR: Odds ratio; PTSD: Posttraumatic stress disorder; SE: Standard also concluded that ADHD and self-injury have a error; SIB: Self injurious behviour; SII: Self inflicted injury; SIQ: Self-Injurious strong association, as we did, so these results support Questionnaire; SITBI: Self-Injurious Thoughts and Behaviors Interview each other. Finally, it is important to underline that our aim was not to focus only on ADHD but on the Acknowledgement Judit Balazs was supported by the János Bolyai Research Scholarship of the whole spectrum of externalizing disorders. Hungarian Academy of Sciences. Another methodological limitation could be that our This work was supported by OTKA K108336 grant. work is a narrative review. A meta-analytic review, or a full meta-analysis would be more useful to compare the Funding There were no direct funding for any part of this study. General funding results of these very heterogenous papers. To handle this supports of our research group can be found in the ‘Acknowledgement’ limitation and make the comparisons easier, sample section. The open access publication fee is warranted by the first author’s sizes, design of the original studies and statistical results university according to an agreement between BMC and Semmelweis University. are presented in Table 1. Another limitation could be that since our focus in Availability of data and materials this review was to investigate the association between Not applicable. Meszaros et al. BMC Psychiatry (2017) 17:160 Page 20 of 21

Authors’ contributions 12. Chou IC, Lin CC, Sung FC, Kao CH. Attention-deficit hyperactivity disorder GM participated in the design of the study, performed the literature search, increases the risk of deliberate self-poisoning: A population-based cohort. participated in the data analysing and drafted the manuscript. LOH Eur Psychiatry. 2014;29:523–7. participated in the design of the study and in the data analysing and drafted 13. Crowell SE, Beauchaine TP, McCauley E, Smith CJ, Stevens AL, Sylvers P. the manuscript. JB participated in the design of the study, coordinated the Psychological, autonomic, and serotonergic correlates of parasuicide among steps of the data analysing and drafted the manuscript. All authors read and adolescent girls. Dev Psychopathol. 2005;17:1105–27. approved the final manuscript. 14. Lam LT. Attention deficit disorder and hospitalization owing to intra- and interpersonal violence among children and young adolescents. J Adolesc Competing interests Health. 2005;36:19–24. The authors declare that they have no competing interests. 15. Vaughn MG, Salas-Wright CP, DeLisi M, Larson M. Deliberate self-harm and the nexus of violence, victimization, and mental health problems in the – Consent for publication United States. Psychiatry Res. 2015;225:588 95. Not applicable. 16. Young S, Gudjonsson GH, Wells J, Asherson P, Theobald D, Oliver B, Scott C, Mooney A. Attention deficit hyperactivity disorder and critical incidents in a Scottish prison population. Personal Individ Differ. 2009;46:265–9. Ethics approval and consent to participate 17. Zlotnick C, Mattia JI, Zimmerman M. Clinical correlates of self-mutilation in a Not applicable. sample of general psychiatric patients. J Nerv Ment Dis. 1999;187:296–301. 18. Bacskai E, Czobor P, Gerevich J. 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