Procedia - Social and Behavioral Sciences 114 ( 2014 ) 372 – 376

1877-0428 © 2013 The Authors. Published by Elsevier Ltd.Selection and peer-review under responsibility of Academic World Education and Research Center.doi: 10.1016/j.sbspro.2013.12.714

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4th World Conference on Psychology, Counseling and Guidance WCPCG-2013

Alexithymia and personality disorders in the Adolescent Non-suicidal Self Injury: preliminary results

Rita Cerutti a*, Monia Calabrese a, Carmela Valastro a

a Sapienza University, Department of Dynamic and Clinical Psychology, Via degli Apuli 1, Rome 00185, Italy

Abstract

The aim of the present study was to describe the characteristics of repetitive self-injurious behaviour and related personality functioning as well as to explore the relationship between NSSI and alexithymia in a sample of NSSI adolescents (mean age= 16.1 yrs) within therapeutic communities. The results showed a representation of Cluster B personality features and personality disorders (e.g., borderline, narcissistic, antisocial). A significant association between NSSI behaviours and alexithymia was found. Additionally, the data supported the use of SWAP-200-A as an instrument for assessing personality functioning and personality pathology in adolescents who self-injure. Future research will be necessary to confirm these results. © 2013 The Authors. Published by Elsevier Ltd. Selection and peer-review under responsibility of Prof. Dr. Tülay Bozkurt, Istanbul Kultur University, Turkey Keywords: Non-suicidal self injury (NSSI), adolescents, alexithymia, personality disorders; Swap-200-A

1. Introduction

Non-suicidal self injury (NSSI) refers to the deliberate, self-inflicted destruction of body tissue resulting in immediate damage, without suicidal intent, for purposes not socially sanctioned; it is distinguished from suicidal behaviours involving an intent to die (Walsh, 2006; Nock, 2010). NSSI has received much interest in research and in literature-reviews during recent years. Literature data have shown that adolescence is a critical period for the onset of self-injurious behaviours (Nock & Prinstein, 2005). NSSI generally begins in early adolescence, between the ages of 12 and 14, with lifetime rates ranging from 13% to 41,9% within community adolescent samples (Ross & Heath, 2002; Zoroglu et al., 2003; Muehlenkamp and Gutierrez, 2004; Laye-Gindhu & Schonert-Reichl, 2005; Lundh et al. 2007; Hilt et al., 2008; Cerutti et al. 2011) and from 40% to 80% in adolescent psychiatry patients (Darche, 1990; Nock & Prinstein, 2004).

Common methods include skin cutting, burning, scratching, self -hitting (Nock, 2010). These behaviours can occur episodically or recurrently, and the recurrence frequency is considered to be indicative of the severity of NSSI. Moreover NSSI is frequently associated with psychiatric and personality disorders (Nock & Prinstein, 2004). There is evidence of high rates of DSM-IV Axis I and II psychopathology among clinical samples of

* Corresponding author name. Tel.: +39-06-49917936 E-mail address: rita.cerutti@uniroma1.it

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© 2013 The Authors. Published by Elsevier Ltd.Selection and peer-review under responsibility of Academic World Education and Research Center.

373 Rita Cerutti et al. / Procedia - Social and Behavioral Sciences 114 ( 2014 ) 372 – 376

adolescent self-injurers (Nock et al., 2006; Muehlenkamp et al., 2011); furthermore such behaviour may function to regulate or escape painful emotions (Chapman, Gratz, & Brown, 2006).

Despite good evidence of the relationship between NSSI and alexithymia (Paivio & McCulloch, 2004; Evren & Evren, 2005; Swannell et al., 2012) few studies explored the role of emotional responding as well as the capacity to understand and express emotional states in adolescents who self-injure.

The aim of the current study was to examine NSSI characteristics (such as form, frequency, and function) within a clinical sample as well as to investigate the relationship between NSSI, alexithymia and personality disorders.

The study set up inclusion criteria taking into account the proposed diagnostic criteria of NSSI disorder in the new Diagnostic and Statistical Manual of Mental Disorder (DSM-5; American Psychiatric Association, 2010). Consequently, a history of at least 5 or more self-injurious behaviours was considered.

As such the qualification for this disorder should require more than a single episode and the first step in clinical and research setting will be to try distinguishing between individuals who self-injure repetitively and those who engage in NSSI occasionally.

2. Method

1.1. Participants

The sample was composed of 15 Italian adolescents recruited from adolescents’ therapeutic communities located in an urban area in the centre of Italy. All subjects who presented NSSI over a 12-month period were included. Adolescents diagnosed with intellectual disabilities, pervasive developmental disorders, schizophrenia spectrum disorders or associated neurological conditions were excluded. Five adolescents failed to meet inclusion criterion and so were excluded. The final sample consisted of 10 females with a mean age of 16.1 years (SD=1.1) all having, at the time of administration, a history of repetitive self-injurious behaviour.

2.2. Instruments The Deliberate Self-Harm Inventory (DSHI; Gratz, 2001; Italian version by Cerutti et al., 2012) is a 17-item

self-report measure that assesses lifetime history of various aspects of NSSI (defined as the deliberate, direct destruction of body tissue without suicidal intent), including frequency, duration, and type of NSSI behaviours. Specifically, the DSHI asks participants whether and how often they were engaged in a variety of behaviours “intentionally (i.e., “on purpose”). The subject is required to report the relative frequency of each type of behaviour on a 5-level scale: never-seldom-sometimes-often-always. Gratz (2001) reported a Reliability index (Cronbach’s alpha) of 0.83 and a test-retest coefficient of 0.68 over a period of 2-4 weeks.

The Repetitive Non-Suicidal Self-Injury Questionnaire (R-NSSI-Q, Manca et al., 2005) is a 15-item self-report measure designed to assess repetitive NSSI behaviour and to identify its essential features. Each item is rated on a 5-point Likert-like scale (1 = “Does not describe me at all”; 5 = “Describes me completely”) exploring what the self-injurer feels immediately before, during and immediately after the act of self-injury has been committed.

The 20-Item Toronto Alexithymia Scale (TAS-20) (Bagby, Parker & Taylor, 1994) is a 20-item self-report measure, the most widely used for assessing alexithymia in both research and clinical practice. Each item is rated on a five-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree), with five items negatively keyed. Factor analysis have consistently yield three factors that assess the salient features of the alexithymia construct: Difficulty Identifying Feelings; Difficulty Describing Feelings; Externally-Oriented Thinking. To assess the prevalence of alexithymia, the TAS-20 scores were categorised according to suggested cut off: total score ≥61, indicating alexithymia; 52 to 60, borderline and <51, indicating no alexithymia. The TAS-20 demonstrated good psychometric properties.

Shedler, Westen Assessment Procedure for Adolescent Swap-200-A (Westen et al. 2003) is a standardized assessment instrument for adolescent personality derived from the original adult form, the SWAP-200 (Westen & Shedler, 1999). The SWAP-200 is a Q-sort instrument designed to assess personality pathology, including the DSM–IV PDs. A Q-sort is a set of statements about personality and personality dysfunction. The SWAP-A is comprised of 200 personality-descriptive items which are scored by the clinician (or psychotherapist) based on the clinician’s observations and understanding. The clinician describes a patient by ranking or ordering the

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statements into eight categories, from those that are most descriptive (assigned a value of 7) to those that are not descriptive (assigned a value of 0). Thus, the SWAP yields a score from 0 to 7 for each of 200 personality-descriptive items.

3. Statistical Analysis SPSS 19.0 (Statistical Package for Social Sciences) software package was used for data analysis. Descriptive statistical analysis, frequencies and Pearson correlation were used.

4. Results

All participants reported a history of NSSI, at least five or more self-injurious behaviours in the last year. The age of onset of NSSI ranged between 12 and 13 years indicating a relatively long history of this behaviour in the study group. Similar age of onset of NSSI were found in other adolescent clinical samples and in the general population (Cerutti et al., 2011).

The most frequent behaviours reported by the adolescents were “Cutting” (endorsed by 100% of females), followed by “Scratching”(60%),“Interfering with wounds’ healing” (60%), “Burning“ (30%), “Carving” (50%) and “Sticking Pins”(30%).

Participants reported what they felt immediately before, during and immediately after the act of self-injury in the following items of R-NSSIQ: “I sometimes harm myself to reduce a persistent feeling of distress” (90%); “I am disappointed by my inability to control myself when it last happened”(80%); “When I harm myself, I feel estranged from the world” (40%); “I sometimes feel that there is something inside me that forces me to harm myself”(40%).

All the subjects of the sample showed high scores on Tas-20 (M=67,7; SD=10,58) above the clinical threshold indicating alexithymia (clinical cut-off ≥61). In addition, a positive and significant correlation between NSSI and alexithymia was found (r=.784, p<.0,01).

The data obtained from the SWAP-200-A showed a significant representation of Cluster B personality features and personality disorders (e.g., borderline, narcissistic, antisocial) as well as emotionally dysregulated features in the great majority of the subjects who engaged in NSSI. After the specific analysis of the profiles emerged on SWAP-200-A, data showed that 70% of the subjects reported features of disorder related to antisocial/psychopathic factor while 60% reported features of disorder related to the emotional dysregulation factor. 5. Discussion

The purpose of this study is to add further information to existing literature for a better understanding of the NSSI characteristics and its relationship with alexithymia and personality functioning within a clinical sample of adolescents.

All participants reported a history of repetitive self-injury and showed multiple types of self-injurious behaviour with a higher frequency of severe forms of NSSI (e.g., Cutting). As already found out in a previous research (see Jacobson & Gould, 2007), the age of onset of the first-ever self-injurious behavior was 12 years for a high percentage of subjects (40%).

Furthermore, the data support the possibility to use SWAP-200-A as an instrument for assessing personality functioning and personality pathology in adolescents who self-injured. The presence of NSSI was found to be consistently more related to cluster B personality features (e.g., antisocial/psychopathic) and personality disorder. These results are interesting considering that the entire sample was composed of females and research demonstrated that NSSI is most often associated with borderline personality disorder (BPD; Dulit et al., 1994; Nock et al., 2006).

Additionally, in this sample, adolescents who engage in repetitive NSSI are more likely to have high level of alexithymia as well as higher scores on the items of SWAP-200-A which explore emotional dysregulation. One consequence of alexithymia is the difficult regulation or management of the emotional expression that is important in interpersonal relationships. Emotional regulation has been identified as a specific component of

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emotional competence (Way et al., 2007). Emotional regulation relies on the ability to understand and express emotions and involves effective and organized management of both negative and positive emotions. The ability to understand and express emotions is important to manage one’s own emotions and understand the feelings of others (Thompson, 2002). Not surprisingly, the results of this study highlight a positive correlation between alexithymia and NSSI behaviours and the high presence of emotionally dysregulated features seems to confirm the hypothesis that NSSI is primarily maintained by negative emotional reinforcement and is particularly devoted to the reduction of negative emotional states (Chapman et al. 2006; Klonsky, 2007; Nock 2010). The emotionally dysregulated features of these adolescents, all females, could account for the need to resort to NSSI for self-regulation. However, the small sample (n = 10) limits the generalization of these findings. Future research will be necessary to confirm these results.

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