A Functional Approach to the Assessment of Self-Mutilative Behavior
Matthew K. Nock
Mitchell J. Prinstein
This study applied a functional approach to the assessment of self-mutilative behavior (SMB) among
adolescent psychiatric inpatients. On the basis of past conceptualizations of different forms of self-
injurious behavior, the authors hypothesized that SMB is performed because of the automatically
reinforcing (i.e., reinforced by oneself; e.g., emotion regulation) and/or socially reinforcing (i.e.,
reinforced by others; e.g., attention, avoidance–escape) properties associated with such behaviors. Data
were collected from 108 adolescent psychiatric inpatients referred for self-injurious thoughts or behav-
iors. Adolescents reported engaging in SMB frequently, using multiple methods, and having an early age
of onset. Moreover, the results supported the structural validity and reliability of the hypothesized
functional model of SMB. Most adolescents engaged in SMB for automatic reinforcement, although a
sizable portion endorsed social reinforcement functions as well. These findings have direct implications
for the understanding, assessment, and treatment of SMB.
Self-mutilative behavior (SMB) refers to deliberate damage to
one’s own body tissue without suicidal intent and is part of the
larger class of self-injurious behavior that includes actions ranging
from stereotypic skin rubbing to completed suicide. SMB is a
pervasive public health problem, with an estimated rate of 4% of
the general adult population and 21% of adult psychiatric inpatient
populations displaying these behaviors (Briere & Gil, 1998). As
with suicidal thoughts and behaviors, adolescence appears to be a
period of increased risk for SMB. Studies suggest that 14%–39%
of adolescents in the community (Lloyd, 1998; Ross & Heath,
2002) and 40%–61% of adolescents in psychiatric inpatient set-
tings perform these behaviors (Darche, 1990; DiClemente, Ponton,
& Hartley, 1991). The alarmingly high rate at which adolescent
self-injurious behaviors occur, coupled with the psychopathology
and dysfunction often associated with such behaviors (e.g., Nock
& Kazdin, 2002), underscores the need for a better understanding
of how to effectively assess and treat these behaviors.
Despite the dangerousness and pervasiveness of SMB, surpris-
ingly little is known about the nature of this problem. Limitations
in the literature exist at both descriptive and theoretical levels. For
instance, basic aspects of SMB, including the frequency of differ-
ent methods and the average age of onset, have not been well
established. Previous work has focused primarily on describing the
psychosocial constructs associated with the presence of SMB. The
result of this research is a heterogeneous list of diagnostic and
psychosocial characteristics associated with SMB, including
higher scores on measures of suicidal thoughts and behaviors,
depression, anxiety, posttraumatic stress, anger, aggressiveness,
impulsiveness, loneliness, social isolation, and hopelessness
(Darche, 1990; Favazza, 1998; Guertin, Lloyd-Richardson, Spirito,
Donaldson, & Boergers, 2001). Although this research may be
helpful for the identification of those at increased risk for SMB, it
adds little to our understanding of why individuals perform SMB.
We examined SMB in this study using a functional approach
rather than the syndromal approach used in prior studies. Whereas
a syndromal approach focuses on the classification and treatment
of behaviors according to their topographical characteristics (i.e.,
associated signs and symptoms), a functional approach classifies
and treats behaviors according to the functional processes that
produce and maintain them (i.e., antecedent and consequent con-
textual influences). Applications of a functional approach to dif-
ferent forms of psychopathology have led to impressive advances
in the conceptualization, assessment, and treatment of a range of
clinically relevant behavior problems (e.g., Hayes, Wilson, Gif-
ford, Follette, & Strosahl, 1996) but have been surprisingly absent
from previous conceptualizations of SMB.
An examination of past research in this area yielded two sources
of information that guided the current work. First, possible func-
tions of SMB have been proposed in narrative case reports and
theoretical reviews (Favazza, 1998; Suyemoto, 1998) and more
recently in empirical evaluations of SMB (Brown, Comtois, &
Linehan, 2002). Although these sources have not articulated or
evaluated an integrated, theoretically based model of SMB, they
provided a useful point of departure for the current work.
Second, experimental studies of stereotypic self-injurious be-
haviors (e.g., head banging, pica) in developmentally disabled
populations have demonstrated that these behaviors are maintained
through social (i.e., interpersonal, or reinforced by others) and
automatic (i.e., intrapersonal, or reinforced by oneself) contingen-
Support for this work was provided in part by National Institute of
Mental Health National Research Service Award F32-MH11770 to Mitch-
ell J. Prinstein. We thank Elizabeth Lloyd-Richardson for the use of the
Functional Assessment of Self-Mutilation in this study, Dana Damiani and
Joy Richmond for their assistance with data collection, and Wil Cunning-
ham and Stephanie Jones for assistance with data analyses.
Correspondence concerning this article should be addressed to Matthew
K. Nock, Department of Psychology, Harvard University, 33 Kirkland
Street, Cambridge, MA 02138, or Mitchell J. Prinstein, Department of
Psychology, Yale University, Box 208205, New Haven, CT 06520. E-mail:
email@example.com or firstname.lastname@example.org
Journal of Consulting and Clinical Psychology
2004, Vol. 72, No. 5, 885–890
Copyright 2004 by the American Psychological Association
cies (Iwata et al., 1994).1Although stereotypic self-injurious be-
haviors and SMB share some physical features, there are signifi-
cant differences in form and severity, as well as in the clinical
populations in which they typically occur, that highlight the need
for separate evaluation of these phenomena. Nevertheless, these
findings provided a solid basis for generating testable hypotheses
about the functions of SMB.
Drawing on findings from these two sources, we proposed and
evaluated four primary functions of SMB that differ along two
dichotomous dimensions: contingencies that are automatic versus
social and reinforcement that is positive (i.e., followed by the
presentation of a favorable stimulus) versus negative (i.e., fol-
lowed by the removal of an aversive stimulus). Automatic-negative
reinforcement refers to an individual’s use of SMB to achieve a
reduction in tension or other negative affective states (e.g., “to stop
bad feelings”). This function is the most commonly invoked in
theoretical reports, and there is some empirical evidence support-
ing the automatic-negative reinforcing properties of SMB. One
experimental study revealed that compared with nonmutilators,
individuals who had engaged in SMB showed a decrease in psy-
chophysiological and subjective response during a self-mutilation
imagery task (Haines, Williams, Brain, & Wilson, 1995), which
provided initial support for the existence of such a function of
SMB. In automatic-positive reinforcement, individuals engage in
SMB to create a desirable physiological state (e.g., “to feel some-
thing, even if it was pain”). In other words, rather than serving the
purpose of removing feelings, SMB may also function as a means
of feeling generation (Brown et al., 2002).
In contrast, social reinforcement functions refer to the use of
SMB to modify or regulate one’s social environment. Social-
negative reinforcement refers to an individual’s use of SMB to
escape from interpersonal task demands (e.g., “to avoid punish-
ment from others” or “to avoid doing something unpleasant”). The
existence of this function has not been widely discussed in the
theoretical literature; however, a similar function was proposed by
Brown et al. (2002) with regard to adult women with borderline
personality disorder, although empirical support was mixed in that
study. Social-positive reinforcement for SMB involves gaining
attention from others or gaining access to materials (e.g., “to try to
get a reaction out of someone, even if it’s negative” or “to let
others know how unhappy I am”). The notion that adolescents
sometimes engage in SMB to gain attention or to manipulate
others is often discussed in theoretical articles on SMB and is a
well-known piece of clinical lore; yet, like the other proposed
functions, this notion has received little empirical support. Thus,
one of our primary goals in the current study was to empirically
evaluate this four-function model of SMB.
Our main goal in this study was to examine the reasons adoles-
cents endorsed engaging in SMB and to test whether these reasons
can be reliably classified into the four theoretically derived func-
tions of SMB. As a preliminary step, we evaluated basic charac-
teristics of SMB, including the frequency of different methods and
average age of onset.
Data were collected among clinically referred adolescents ad-
mitted to a psychiatric inpatient unit to examine this functional
model among those at severe risk for SMB. Following the meth-
odology used in previous studies (Boergers, Spirito, & Donaldson,
1998; Brown et al., 2002), we solicited individuals’ self-reports of
the perceived reasons for engaging in SMB and used this infor-
mation to examine the hypothesized, overarching functions of such
behaviors. Although the use of self-report to examine the func-
tional determinants of an individual’s behavior differs from the
behavioral tradition from which this methodology originated, it
allowed for (a) an examination of reinforcement that is automatic
and thus less detectable by external informants as well as (b) an
assessment of SMB that occurs outside the inpatient setting.
Participants were 108 adolescents (32 boys, 76 girls) age 12–17 years
(M ? 14.8, SD ? 1.4) who were drawn from consecutive admissions to an
adolescent psychiatric inpatient unit in New England. The ethnic compo-
sition of the sample was 72.2% European American, 11.2% Latin Amer-
ican, 4.6% African American, and 12.1% mixed ethnicity–other. Accord-
ing to state census tract data, socioeconomic status for adolescents in this
sample was 3.0% high, 57.6% moderate, 24.2% low, and 15.2% poverty.
Data were obtained from a comprehensive intake evaluation routinely
administered to all adolescent inpatients and a supplemental clinical eval-
uation conducted with all inpatients referred for self-injurious thoughts or
behaviors. The use of data from each patient’s clinical record was approved
for research purposes by the hospital’s institutional review board. Adoles-
cents included in the present study were those classified by the admitting
psychiatrist as exhibiting self-injurious thoughts or behaviors. Patients with
active psychosis or mental retardation were excluded. For participants
admitted to the inpatient unit on more than one occasion during the study
period, data from only the first admission were used.
The Functional Assessment of Self-Mutilation (FASM; Lloyd, Kelley, &
Hope, 1997) is a self-report measure of the methods, frequency, and
functions of SMB. Items regarding the methods and functions of SMB
were initially developed through an extensive review of past literature on
SMB in both normative and psychiatric populations. Next, a series of
independent focus groups were conducted with psychiatric inpatient ado-
lescents who had engaged in SMB to supplement the list of methods and
functions extracted from past research. Thus, all items on the FASM reflect
behaviors that were generated by adolescents with histories of SMB and
are generally consistent with past research (see Lloyd, 1998).
Participants first indicated whether and how often they had engaged in
11 different methods of SMB in the previous 12 months, with a space
provided for any methods not listed. To assess the functions of SMB,
participants were then asked how often they had engaged in SMB for each
of 22 different reasons (scored from 0 ? never to 3 ? often for each item),
with a space provided for any reasons not listed. Other aspects of the
participants’ SMB, such as age of onset, were also assessed.
The FASM has been used in studies of both normative (Lloyd, 1998;
Lloyd et al., 1997) and psychiatric samples (Guertin et al., 2001), which
have yielded support for its psychometric properties. For instance, Guertin
et al. (2001) reported adequate levels of internal consistency for the FASM
for both moderate and severe forms of SMB (r ? .65–.66). Studies have
1We use the term automatic to refer to reinforcement that is conducted
or carried out by oneself, which is consistent with previous research in
applied behavior analysis; the term does not refer to behavior that is
performed without conscious effort, which is a definition often used in
also supported the concurrent validity of the FASM as evidenced by
significant associations with measures of suicidal ideation and the presence
of a past suicide attempt (Guertin et al., 2001; Lloyd et al., 1997).
However, no previous investigations have evaluated the theoretically de-
rived functions that were the focus of the present study.
Several data-analytic strategies were used to evaluate the main study
hypotheses. We used descriptive statistics to examine the frequency of
different methods and the basic characteristics of SMB. Various data-
analytic procedures were then used to evaluate the structural validity of our
four-function model. First, each of the reasons from the FASM was
assigned to one of the four functions according to expert consensus
(between Matthew K. Nock and Mitchell J. Prinstein). We then evaluated
the structural validity of our four-function model by submitting the reasons
given for SMB to a confirmatory factor analysis (CFA) using LISREL 8.5
(Jo ¨reskog & So ¨rbom, 1996) and evaluated the four subscales in reliability
analyses. In this case, the structural validity of our four-function model
would be supported if our CFA showed an adequate degree of fit between
the data and our hypothesized model. Although our sample size was
relatively small, it is notable that power analyses indicated that given the
degrees of freedom of the hypothesized model and with alpha set at .05, our
level of statistical power (.79) approximated the accepted level necessary
(.80) to test the hypothesis that our model is a close fit with the data (see
MacCallum, Browne, & Sugawara, 1996).
Frequency and Characteristics of SMB
Overall, 82.4% (n ? 89) of the adolescents in this sample
reported engaging in at least one incident of SMB in the previous
12 months (i.e., 17.6% reported engaging in self-injurious thoughts
or suicide attempts but not SMB). Of those who engaged in at least
one incident of SMB, the mean number of incidents in the past
year was 80.0 (SD ? 132.3, Mdn ? 19.0, Mode ? 2.0, range ?
1–745). Only 6 (7%) of the self-mutilators reported engaging in
only one incident of SMB, and 45 (50.6%) of the adolescents
reported 19 or more incidents in the previous 12 months. Data on
the frequency of the 11 methods of SMB queried in the FASM are
presented in Table 1. No participants endorsed using any methods
of self-mutilation other than those listed in Table 1.
Self-mutilators were more likely to be female (74.2%) than male
(25.8%); however, these rates were consistent with the gender
breakdown of this sample, and there was no significant gender
difference for the presence of SMB, ?2(1, N ? 108) ? 3.48, ns.
Most individuals began engaging in SMB in early adolescence,
although some reported doing so during childhood (age of onset in
years: M ? 12.8, SD ? 2.1, Mdn ? 13.0, Mode ? 13.0, range ?
6–17). There were no significant age, gender, or ethnic differences
for frequency, methods, or age of onset.
Functions of SMB
goodness-of-fit of confirmatory structural equation models, includ-
ing nonsignificant ?2, incremental fit index (IFI) ? .90, compar-
ative fit index (CFI) ? .90, root-mean-square error of approxima-
tion (RMSEA) ? .05, and ?2/df ? 2 (Browne & Cudeck, 1993).
These last three indices are less biased by sample size than other
fit statistics and are of particular importance given the relatively
small sample used in this study. The results of the CFA indicate an
acceptable degree of fit between the data and our hypothesized
model. Although the chi-square value for the final model was
statistically significant, ?2(176, N ? 89) ? 248.42, p ? .02,2
which suggests less than optimal fit, other statistics suggest that the
model was a good fit with the data, IFI ? .91, CFI ? .90,
RMSEA ? .05 (90% confidence interval ? .03–.07), and ?2/df ?
1.41. Twenty-one of the 22 items loaded significantly on the
proposed factors (1 item was removed from the analyses because
of failure to load on any factor), and the resulting factor loadings
are presented in Table 2. Model modification tests revealed no
cross-loadings that would significantly improve the model fit,
Several fit index values can be used to determine
2The FASM contains several pairs of items that are similar in content
(e.g., Item 8 ? to receive more attention from your parents or friends and
Item 3 ? to get attention). It was expected that such items would share
nonrandom error variance given the similarities in wording. To account for
this nonrandom error, we allowed for correlated residuals between several
such items, as suggested by Lagrange multiplier tests.
Frequency of Each Method of Self-Mutilative Behavior
Method of self-mutilative behavior
No.%No.% No.% No.% No.%
Cutting or carving on skin
Picking at a wound
Scraping skin to draw blood
Picking areas of the body to the point of drawing blood
Inserting objects under skin or nails
Pulling out one’s own hair
Erasing skin to draw blood
Total (n ? 89 self-mutilators)
which suggests that each item loaded only on the proposed factor.
Overall, the goodness of fit of this model supports the hypothe-
sized four-function structure of SMB. It is notable that we also
tested models with one, two (social reinforcement and automatic
reinforcement), and three (social-positive reinforcement, social-
negative reinforcement, and automatic reinforcement) functions.
Chi-square difference tests revealed that the two-, three-, and
four-function models each provided a significantly better fit with
the data than did the one-function model. Although the two- and
three-function models were more parsimonious than was the four-
function model, these models did not provide better model fit;
therefore, we retained the hypothesized, theoretically derived,
Reliability analyses and correlations among the functions.
The internal consistency of each of the four subscales was evalu-
ated with Cronbach’s alpha coefficients. The resulting alpha co-
efficients (presented in Table 3) ranged from .62 to .85, which
suggests moderate-to-high internal consistency reliability for each
subscale. As hypothesized, the four subscales were significantly
correlated (presented in Table 3). The magnitude of these zero-
order correlations (rs ? .39–.78) indicates shared variance be-
tween 15% and 61% among the subscales and supports our hy-
pothesis that although significantly related, the four functions
represent distinct (i.e., not redundant) constructs.
Level of endorsement of overall functions and individual rea-
sons of SMB.
The relative frequency of each of the four functions
and the specific reasons endorsed most frequently by self-
mutilators were also evaluated. The mean item response for each
subscale is presented in Table 3. A repeated measures analysis of
variance indicated a significant overall difference among the sub-
scales, F(1, 86) ? 23.21, p ? .01, Cohen’s f ? .92. Post hoc paired
t tests examining differences between subscales revealed that (a)
scores on the automatic-negative reinforcement subscale were
significantly higher than on all other subscales (all ps ? .01), (b)
scores on the automatic-positive reinforcement subscale were sig-
nificantly higher than on both social reinforcement subscales
Confirmatory Factor Analysis and Rate of Reported Reasons for Engaging in Self-Mutilation
% of self-mutilators
(n ? 89)
14. To stop bad feelings
2. To relieve feeling numb or empty
10. To punish yourself
22. To feel relaxed
4. To feel something, even if it was pain
5. To avoid doing something unpleasant you don’t want to do
1. To avoid school, work, or other activities
13. To avoid punishment or paying the consequences
9. To avoid being with people
6. To get control of a situation
11. To get other people to act differently or change
7. To try to get a reaction from someone, even if it’s negative
17. To get your parents to understand or notice you
21. To make others angry
12. To be like someone you respect
18. To give yourself something to do when alone
8. To receive more attention from your parents or friends
16. To feel more a part of a group
15. To let others know how desperate you were
3. To get attention
20. To get help
19. To give yourself something to do with othersa
aThis item was excluded.
A-NR ? Automatic-negative reinforcement; A-PR ? automatic-positive reinforcement; S-NR ? social-negative reinforcement; S-PR ? social-
Alpha Coefficients, Mean (and SD) Item Response, and Zero-Order Correlations for the Four
1. Automatic-negative reinforcement
2. Automatic-positive reinforcement
3. Social-negative reinforcement
4. Social-positive reinforcement
(ps ? .01), and (c) there was no difference between scores on the
social-reinforcement subscales, t(88) ? 1.62, ns.
To provide additional clinical information, we also evaluated the
rate of endorsement of each individual reason, as presented in
Table 2. The items related to the automatic-reinforcement func-
tions were endorsed much more frequently than items related to
the social-reinforcement functions. For instance, more than half of
all self-mutilators (52.9%) reported that they engaged in SMB “to
stop bad feelings.” Overall, items on the automatic-reinforcement
subscales were endorsed by 24%–53% of self-mutilators, whereas
the items on the social-reinforcement subscales were endorsed by
only 6%–24% of self-mutilators. Thus, self-mutilators reported
engaging in SMB to regulate their emotions much more frequently
than to influence the behavior of others.
Our results indicate that SMB is quite prevalent, occurs via
multiple methods, and begins at a relatively early age in adolescent
psychiatric inpatients. These findings highlight the importance of
understanding why individuals perform SMB and ultimately what
interventions are most efficacious at decreasing these behaviors.
Perhaps the greatest contribution of this study is the articulation
and empirical support for a functional model of SMB. Our findings
indicate that adolescents engage in SMB for a variety of reasons
that are consistent with learning theory. Reasons related to auto-
matic reinforcement were endorsed most frequently, which sug-
gests that the primary purpose of most adolescent SMB is the
regulation (i.e., both decrease and increase) of emotional or phys-
iological experiences. Our results also provide empirical support
for social-reinforcement functions of SMB, which have long been
the object of clinical theory but have received little empirical
attention. Although not endorsed as frequently as the automatic-
reinforcement functions, social reinforcement was endorsed by a
significant portion of adolescent self-mutilators and is considered
a significant factor influencing the occurrence of SMB. On bal-
ance, it is possible that automatic-reinforcement functions are
endorsed more frequently than social functions because adoles-
cents who engage in SMB are more socially isolated from the
outset (Guertin et al., 2001) and thus lack the opportunity for social
The support for these four functions suggests different learning
experiences may be involved in the development of SMB and,
similarly, that diverse treatment approaches may be needed to
effectively reduce SMB. Clinicians should consider using different
therapeutic approaches according to the identified function of
SMB, and interventions may be most effective if aimed at replac-
ing SMB with functionally equivalent behaviors. For instance, if
an individual’s SMB is maintained via automatic reinforcement, it
is likely that therapeutic approaches that focus on enhancing
alternative-affect regulation skills would be most effective. Alter-
natively, if an individual’s SMB is maintained via social reinforce-
ment, it is likely that approaches that focus on teaching more
adaptive interpersonal communication skills would be most appro-
priate (see Linehan, 1993; Miller, 1999; Rudd, Joiner, & Rajab,
2001). The evaluation of the efficacy of such a functionally guided
treatment approach represents a rich area for future research on
Future studies in this area should consider several limitations of
this investigation. First, this study was conducted within a rela-
tively small sample of adolescent inpatients referred for self-
injurious thoughts or behaviors. Although we had sufficient sta-
tistical power to test the primary study hypotheses, our sample size
was smaller than that commonly used in CFA, and our results
should be considered preliminary until replicated with a larger
clinical sample. Second, the method of assessment relied exclu-
sively on self-report at one time point. It is possible that observed
relationships between variables may have been increased because
of shared method variance. Future researchers would improve on
this study by using multiple informants, performance-based assess-
ment methods, and the collection of data over several time points
to ensure the validity and reliability of observed results (see
Prinstein, Nock, Spirito, & Grapentine, 2001). It also would be
instructive to examine whether individuals engage in SMB for
multiple functions at one time or whether functions tend to differ
over time within individuals. The answers to these key questions
will help us better understand the correlations among the four
functions observed in this study and will have significant impli-
cations for the assessment and treatment of SMB. Finally, although
these preliminary data support the structural validity and reliability
of our four-function model, support for the construct validity of the
model is needed.
Overall, this study offers an integrated, theoretically based
model of the functions of SMB in adolescents. Given the high
prevalence of this behavior, particularly among clinically referred
populations, and the lack of prior empirical research in this area,
these results provide an important initial step in conceptualizing
SMB in a manner that could be immediately useful in the assess-
ment and treatment of adolescents. We hope the model of SMB
articulated and evaluated in this study will stimulate future re-
search on this pervasive and life-threatening behavior problem.
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Received May 1, 2002
Revision received October 17, 2003
Accepted October 29, 2003 ?
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