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The Ottawa Self-Injury Inventory: Evaluation of an assessment measure of nonsuicidal self-injury in an inpatient sample of adolescents


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The Ottawa Self-Injury Inventory (OSI) is a self-report measure that offers a comprehensive assessment of nonsuicidal self-injury (NSSI), including measurement of its functions and addictive features. In a preliminary investigation of self injuring college students who completed the OSI, exploratory analysis revealed four function factors (Internal Emotion Regulation, Social Influence, External Emotion Regulation and Sensation Seeking) and a single Addictive Features factor. Rates of NSSI are particularly high in inpatient psychiatry youth. The OSI can assistin both standardizing assessment regarding functions and potential addictive features and aid case formulation leading to informed treatment planning. This report will describe a confirmatory factor analysis (CFA) of the OSI on youth hospitalized in a psychiatric unit in southwestern Ontario. Demographic and self-report data were collected from all youth consecutively admitted to an adolescent in-patient unit who provided consent or assent. The mean age of the sample was 15.71 years (SD = 1.5) and 76 (81 %) were female. The CFA proved the same four function factors relevant, as in the previous study on college students (χ (2)(183) = 231.98, p = .008; χ (2)/df = 1.27; CFI = .91; RMSEA = .05). The model yielded significant correlations between factors (rs = .44-.90, p < .001). Higher NSSI frequency was related to higher scores on each function factor (rs = .24-.29, p < .05), except the External Emotion Regulation factor (r = .11, p > .05). The factor structure of the Addictive Features function was also confirmed (χ (2)(14) = 21.96, p > .05; χ (2)/df = 1.57; CFI = .96; RMSEA = .08). All the items had significant path estimates (.52 to .80). Cronbach's alpha for the Addictive Features scale was .84 with a mean score of 16.22 (SD = 6.90). Higher Addictive Features scores were related to more frequent NSSI (r = .48, p < .001). Results show further support for the OSI as a valid and reliable assessment tool in adolescents, in this case in a clinical setting, where results can inform case conceptualization and treatment planning.
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RES E A R C H A R T I C L E Open Access
The Ottawa Self-Injury Inventory: Evaluation
of an assessment measure of nonsuicidal
self-injury in an inpatient sample of adolescents
Mary K Nixon
, Christine Levesque
, Michèle Preyde
, John Vanderkooy
and Paula F. Cloutier
Background: The Ottawa Self-Injury Inventory (OSI) is a self-report measure that offers a comprehensive assessment of
nonsuicidal self-injury (NSSI), including measurement of its functions and addictive features. In a preliminary investigation
of self injuring college students who completed the OSI, exploratory analysis revealed four function factors (Internal
Emotion Regulation, Social Influence, External Emotion Regulation and Sensation Seeking) and a single Addictive Features
factor. Rates of NSSI are particularly high in inpatient psychiatry youth. The OSI can assistin both standardizing assessment
regarding functions and potential addictive features and aid case formulation leading to informed treatment planning.
This report will describe a confirmatory factor analysis (CFA) of the OSI on youth hospitalized in a psychiatric unit in
southwestern Ontario.
Methods: Demographic and self-report data were collected from all youth consecutively admitted to an adolescent
in-patient unit who provided consent or assent.
Results: The mean age of the sample was 15.71 years (SD = 1.5) and 76 (81 %) were female. The CFA proved the same
four function factors relevant, as in the p revious study on college students (χ
(183) = 231.98, p = .008; χ
/df =
1.27; CFI = .91; RMSEA = .05). The model yielded significant correlations between factors (rs = .44-.90, p < .001).
HigherNSSIfrequencywasrelatedtohigherscoresoneachfunctionfactor(rs = .24-.29, p < .05), except the
ExternalEmotionRegulationfactor(r = .11, p > .05). The factor structure of the Addictive Features function was
also confirmed (χ
(14) = 21.96, p > .05; χ
/df = 1.57; CFI = .96; RMSEA = .08). All the items had significant path
estimates (.52 to .80). Cronbachs alpha for the Addictive Features scale was .84 with a mean score of 16.22
(SD = 6.90). Higher Addictive Features scores were related to more frequent NSSI (r = .48, p < .001).
Conclusions: Results show further support for the OSI as a valid and reliable assessment tool in a dolescents,
in this case in a clinical setting, where results can inform case conceptualization a nd treatment planning.
Keywords : Nonsuicidal self-injury, Assessment, Functions, Addictive features, Youth
Early adolescence is the peak period of onset for non
suicidal self-injury (NSSI) [1] providing, if detected, an
opportunity for early intervent ion as the youth is at risk
of developing a repetitive maladaptive coping strategy.
In clinical practice, there are curre ntly no routine
standardized self report mea sures used to inform the
understanding a nd treatment of N SSI despite it s high
prevalence rates in clinical populations [2, 3]. The
majority of NSSI measures remain research tools.
Having a mea sure of N SSI that is valid and clinically
useful can inform case conceptualization and treat-
ment planning.
While the clinical interview provides important infor-
mation and the opportunity to develop a therapeutic
alliance, many youth may not share the extent of their
NSSI due to shame or difficul ty expressing themselves
fully in one on one questioning. Many find that
self report measures are helpful to share information
they would otherwise be reluctant to disclose [4]. In
* Correspondence:
Equal contributors
Queen Alexandra Centre for Childrens Health, 2400 Arbutus Rd, Victoria, BC
V8N 1V7, Canada
Full list of author information is available at the end of the article
© 2015 Nixon et al. This is an Open Access article distributed under the terms of the Creative Commons Attribution License
(, which permits unrestricted use, distribution, and reproduction in any medium,
provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http:// applies to the data made available in this article, unless otherwise stated.
Nixon et al. Child and Adolescent Psychiatry and Mental Health (2015) 9:26
DOI 10.1186/s13034-015-0056-5
addition, clinicians may not be able to provide as com-
prehensive questioning specific to NSSI nor necessarily
have the time to do so in the first assessment interview.
Many aspects of NSSI have been poorly understood in
terms of its functions and other characteristics. The
Diagnostic and Statistical Manual of Mental Disorders,
Edition (DSM-5) [5] has included criteria for NSSI to
the section requiring further study indicating that
NSSI requires more research and proposing that NSSI
does not solely exist as a symptom of borderline person-
ality disorder.
Theories regarding the reasons or functions of NSSI
have been postulated for several decades with an under-
standing that NSSI may serve more than one function
[6]. Klonsky [7] completed a comprehensive review of
theoretical und erstandings of the functions of NSSI and
research to date in the field. Seven main categori es
of functions of NSSI were derived from this review:
affect regulation, self-punishment, antidissociation, inter-
personal influence, interpersonal boundaries, sensation-
seeking, and anti-suicide. The most commonly endorsed
reason for NSSI is affect regulation with the intent to
relieve negative affective states such as tension, depres-
sion, and/or anger. This category was the most highly
endorsed function in a study of hospitalized adolescent s
where the mean number of en dorsed reasons per indi-
vidual, regardless of category of function, was approxi-
mately eight [8]. In a paper entitled Why do people
hurt themselves?, M. Nock provides an integrated the-
oretical model of the development and maintenance of
NSSI. Distal risk factors such as genetic predisposition
to high emotional/cognitive reactivity, intra and inter-
personal vulnerability factors, responses to stress and
specific NSSI vulnerability factors in the generation of
NSSI are illustrated in how they may interact. This
model helps to consider those at more risk for develop-
ment of NSSI and incorporates the role and underpin-
nings of the potential functions of NSSI [9].
There remains some controversy regarding whether
NSSI can become an addictive behaviour despite many
youths self reporting this anecdotally and several studies
providing evidence of addictive features. In a clinical
study of youth with NSSI to study addictive features,
Nixon Cloutier and Aggarwal [8], showed that 97.6 % of
a clinical sample of 42 repetitive self injuring adolescents
endorsed at least three dependence items on a seven-
point criteria scale for addictive features of NSSI. This
scale was adapted from the Diagnostic Statistical Manual
of Ment al Disorders IV TR (substance dependence cri-
teria) [10]. Schaub, Holly, Toste, and, Heath [personal
communications, 2006], in a university sample of self-
injurers, showed that 31 % endorsed at least three of the
addictive features using the same seven-item scale. More
recently, Moumne, Heath, Schaub, and Nixon [personal
communications; 2014] found that of 137 out of 710
high school students surveyed that endorsed lifetime
presence of NSSI, 20.4 % reported three or more Addi-
tive Features on the OSI addictive features scale. Those
with addictive features had higher frequency, more
methods and more locations of NSSI. Opposing the
concept that NSSI has the potential as an addictive be-
haviour, Victor, Glenn, and Klonsky [11] found in com-
paring drug users and self injuring adolescents that
cravings occurred primarily while experiencing negative
emotions for NSSI with cravings of drug users being
higher than that of self injurers.
In re views o f N SSI asses sment tools [12, 13] there
appears to be significant va riability in functions that
are mea sured between a ssessment tools. Despite the
number of self-report measures asses sing NSSI func-
tions (e.g., Inventory of Statements About Self-Injury
[14], Functional Ass essment of Self-Mutilation [15])
none, e xcept the OSI, assess potential addictive fea-
tures in addition to functions of NSSI. The OSI is a
self-report measure that offers a comprehensive a s -
sessment of NSSI, including both mea surement of it s
functions and potential addictive features. The inventory
was developed based on a comprehensive literature re-
view, clinician feedback and input from adolescent psychi-
atric inpatients with NSSI. It contains a number of scales
including an indication of frequency of recent NSSI
thoughts and acts, reasons for starting and reasons for
continuing to self injure (i.e., functions), addictive features,
level of motivation to stop the behaviour and other char-
acteristics of the nature of NSSI. Youth also respond to
questions regarding what has or has not helped in terms
of previous treatment (s).
The OSI has been previously validated in a commu-
nity sample of self-injuring university students [16].
Explorator y fa ctor analyses revealed four function
factors (Internal Emotion Regulation, Social Influence,
External Emotion Regulation, and Sensation Seeking)
and a single Addictive Features factor. Convergent
evidence for the functions fa ctors scores was demon-
strated through significant correlations with the Func-
tional Assessment of Self-Mutilation measure [15], a
known tool for assessing the functions of NSSI. Con-
vergent evidence w a s also noted for indications of
psychological well being, ris ky behaviours, and con-
text and frequency of NSSI. Convergent e vidence for
the Addictive Features scores was demonstrated
through associations with NSSI frequency, feeling
relieved following the act of NSSI, and the inabi lity to
resist urges to self injure. The conclusions of this pre-
liminary research were that the OSI is a valid and
reliable asse ssment tool that can be used in both re-
search and clinical settings and t hat further research
is warranted.
Nixon et al. Child and Adolescent Psychiatry and Mental Health (2015) 9:26 Page 2 of 7
The purpose of this report is to describe a confirma-
tory factor analysis of the functions and addictive scales
of the Ottawa Self-Injury Inventory (OSI) on youth hos-
pitalized in a child and adolescent psychiatric inpatient
unit in Ontario, Canada. These analyses were performed
on data collected for a study on the characteristics of
youth who accessed inpatient psychiatric care regarding
nonsuicidal self-injury and suicidal behaviour [3]. Com-
prehensive, accessible and user friendly measures such
as the OSI fill a gap in the practice of assessment and
offer clinicians a means to obje ctively assess the behav-
iour in a standardized fashion.
Participants were youth (14 to 18 years old) consecu-
tively admitted between July 2012 and January 2013 to
the Child and Adolescent Inpatient unit who gave con-
sent and completed the OSI. The inpatient unit provides
in-patient crisis, assessment, stabilization and treatment
where the mean length of stay is approximately 5 days.
Youth provided informed consent. Exclusion criteria
were an unstable psychiatric condition (e.g., psychosis
interfering with the ability to provide informed consent),
intellectual disability or pervasive developmental disabil-
ity which was determined by nursing staff. Consenting
youth completed the OSI while in hospital. Research
Ethics Board (REB) approval was obtained from the
Grand River Hospital, Kitchener-Waterloo, Ontario and
the University of Guelph, Guelph, Ontario.
The study included self-reported measures of demo-
graphics and a standardized measure of NSSI. Data were
collected post day two of admission. Youth with a brief
one day admission or held overnight were not included.
Ottawa Self-Injury Inventory (OSI) [16]: This self re-
port inven tory is an in-depth mea sure of occurrence,
frequency, level of motivation to stop, types and func-
tions and potential addictive features of self-injury. The
functions of NSSI are endorsed by indicating the degree
to which 31 items (e.g., to release unbearable tension,
to get care and attention from others) correspond with
their rea sons for engaging in NSSI, ranging from 0,
never a reason,to4,always a reason). Seven questions
were modified from the DSM-IV-TR criteria for sub-
stance dependence to incorporate NSSI as opposed to
substance use . These were used to assess addictive fea-
tures (e.g., Despite a desire to cut down or control this
behaviour, you are unable to do so) with a range
response options from 0 ( never)to4(always) for each
addictive feature. The OSI has been shown to be valid
and reliable with excellent internal consistency scores
of 0.67 to 0.87 in a university sample of young adults
[16] and is appropriate for use with clinical samples of
Data analysis
Demographic data was analysed with descriptive statis-
tics using Statistical Package for the Social Sciences
(SPSS) Version 21 [17]. Confirmatory factor analysis was
used to verify the factor structure of the OSI using
AMOS 20 [18]. In order to optimize the sample size,
missing values were estimated using Expectation
Maximization. None of the items had more than 5 %
missing values, indicating that this option was appropri-
ate for use [19].
In the original sample [3], 322 children and youth were
admitted during the study period and assessed by nurs -
ing staff for possible inclusion in the study: 102 youth
declined to participate or complete the sur vey, or there
were difficulties in obtaining guardian consent, 25 youth
were discharged or on pass before they could be asked
about the study or before the RA could make contact,
72 did not meet inclusion criteria (48 were considered
not appropriate due to psychosis, developmental delay
or violent behaviour, 16 were re-admissions, 6 were ex-
cluded due to age, one had language difficulties, and one
due to extreme fatigue affecting their ability to complete
the questionnaires). Ninety-four participants with a life-
time pre valence of NSSI who completed the functions
section of the OSI were included in this analysis. Almost
half (45.8 %) of the youth reported daily or weekly NSSI
and seventy-three percent (n = 69) reported co-occurring
suicidal ideation and/or behaviour. The mean age was
15.71 (1.5) ran ging from 11 to 20 years of age. Eighty-
one percent of participants were female, 16 % were male,
and one participant was bi-gender. Most youth were at-
tending high school (n = 74), four were in middle school,
and 7 were in college or university. Approximately three
quarters of the sample (n = 42) self reported having symp-
toms of depression.
Confirmatory factor analysis of function scores
A confirmatory factor analysis (CFA) was conduc ted to
confirm the factor structure of the initial functions of
the OSI (Why did you start to self injure?). The model
was composed of four factors (Internal Emotion Regula-
tion, Social Influence, External Emotion Regulation, and
Sensation Seeking). Correlation paths between the factors
were allowed. Bootstrapping (5000 samples) was used to
within the subsample [20]. The fit of the model was
deemed inadequate (χ
(246) = 402.12, p < .001; χ
/df = 1.64;
Nixon et al. Child and Adolescent Psychiatry and Mental Health (2015) 9:26 Page 3 of 7
CFI = .76; RMSEA = .083). Upon further inspection, two
items (to diminish feelings of sexual arousal and to
get care and attention from other people)fromthe
social influence factor did not have significant path
estimates and were therefore removed from the
model. In addition, inspection of the modification in-
dexes revealed that one item ( to stop me from think-
ing about idea s of killing myself ) had significant
correlated errors with another item (to stop me from
acting out ide as of killing myself). This item was also
removed from the model. The fit of the final model
was deemed satisfactory (χ
(183) = 231.98, p = .008; χ
df = 1.2 7; CFI = .91; R MSEA = .05). All the items in
the final model had significant path estimates (stan-
dardized f actor loadings are presented in Table 1 ).
This model also yielded significant correlations be-
tween each fac tors (see Table 2). G reater NSSI fre-
quency wa s related to higher scores on each function
factor (rs=.24.29, p < .05), except for the Exte rnal
Emotion Regulation factor (r =.11, p >.05).
Confirmatory factor analysis of addictive features
Ninety one of ninety four participants completed the
Addictive Features items. The same analytic strategy as
described previously for the function items was con-
ducted on the seven Addictive Features items of the
OSI. The fit of the model was deemed satisfactory
(14) = 21.96, p > .05; χ
/df = 1.57; CFI = .96; RMSEA
= .08). All the items had significant path estimates,
ranging between .52 and .80 (standardize d factor
loadings are presented in Table 3). Cronbachsalpha
for the Addictive Features scale was .84 with a mean
score of 16.22 ( SD = 6.90).
Higher Addictive Features scores were related to more
frequent NSSI (r = .48, p < .001). In addition, no signifi-
cant correlation wa s found between the Addictive
Features factor and feeling of physical pain when self-
injuring (r = .05, p > .0 5). Lastly, significant positive
correlations between the Addictive Features factor
and each of the obtained function factors of the OSI
were obtained (rs=.30.4 4, p <.01).
Table 1 Standardized factor loadings and descriptive statistics for NSSI function factors
Motivations Internal Emotion
External Emotion
To produce a sense of being real when I feel
numb and unreal
To relieve feelings of sadness or feeling down .63
To distract me from unpleasant memories .62
To punish myself .60
To stop feeling alone and empty .56
To experience physical pain in one area, when
the other pain I feel is unbearable
To stop me from acting out ideas of killing myself .50
To stop my parents from being angry at me .56
To stop people from expecting so much from me .55
To change my body image and/or appearance .53
To show others how hurt or damaged I am .50
To avoid getting in trouble for something I did .46
To get out of doing something that I dont
want to do
To belong to a group .29
To release frustration .89
To release anger .80
To release unbearable tension. .62
To experience a high like a drug high .71
To provide a sense of excitement that feels
For sexual excitement .31
To prove to myself how much I can take .26
α .78 .66 .82 .53
Mean scores (SD) 17.78 (7.11) 5.47 (4.93) 8.62 (3.49) 3.69 (3.39)
Nixon et al. Child and Adolescent Psychiatry and Mental Health (2015) 9:26 Page 4 of 7
The current study provides additional support for the psy-
chometric properties of the OSIsfunctionsandAddictive
Features scales in a clinical sample of adolescents. The ori-
ginal factor structure obtained in a university sample [16]
was confirmed. The four-factor model (Internal Emotion
Regulation, Social Influence, External Emotion Regulation,
and Sensation Seeking) of NSSI functions and the single
Addictive Features factor were replicated in this clinical
sample, with few exceptions. Within the Internal Emotion
Regulation factor, the item to stop me from thinking about
ideas of killing myself had significant correlated errors
with the item to stop me from acting out ideas of killing
myself. This is not a surprising finding as the two items
are connected when there is active planning of a suicide
attempt, in that experiencing suicidal ideation commonly
precedes the act of suicide. Under the Social Influence
factor there were two items that did not have significant
path estimates (i.e., did not relate significantly to their
factor), namely, to diminish feelings of sexual arousal
and to get care and attention from other people. It is
unclear why this would be, however, these items may be
under-reported or less commonly reported in adolescent
inpatients. Inpatient samples have typically higher rates
and frequency of NSSI [21] and are likely to have func-
tions endorsed related to managing symptoms associated
with major mental health disorders such as mood and
anxiety problems. Additional research is recommended to
investigate this further.
Convergent evidence was found for scores on both
functions and Addictive Features on the OSI through
significant correlations with theoretical and empirical
constructs. Specifically, greater NSSI frequency was re-
lated to higher scores on each function factor, except for
the External Emotion Regulation factor. This finding fur-
ther supports the notion that frequent NSSI can be both
negatively (Internal Emotional Regulation) and positively
(Sensation Seeking) reinforcing in a clinical sample as
previously found in a non clinical population [16]. The
mean score in this clinical sample was double that ob-
tained in the university sample (16.22 vs 8.05) indicating
that the measure is sensitive enough to detect differ-
ences between samples. These finding s indicate that
clinical samples might have more addictive features of
NSSI than community samples however further research
is required.
An interesting finding is that Social Influence as a
function factor was correlated with frequency of NSSI in
this clinical sample while this was not the case in Martin
and colleagues [16], where the population was somewhat
older and also community based. There may be several
reasons for this finding. Firstly, adolescents as opposed
to young adults are expected to have fewer and less de-
veloped coping strategies [22]. Second, the adolescent
period is particularly stressful in regards to interpersonal
issues, more spe cifically the impact of peer influence
and peer victimization including online bullying [23].
Thirdly, clinical samples typically have greater frequency
of NSSI than non-clinical samples and triggers or rea-
sons for NSSI such as social influence factors are likely
to also be reinforces of the behaviour leading to more
frequent NSSI.
There are several study limitations that should be
mentioned. First and foremost, the sample size limit s
generalizability of the results and research should repli-
cate these findings with large samples. Second, there
were fewer males than females who participated in the
study. However, the gende r proportions obtained are
representative of the ratio of females to males admitted
to adolescent inpatient care [2, 8]. Further research on
Table 3 Standardized factor loadings and descriptive statistics
for NSSI Addictive Features
Items Addictive
The self-injurious behaviour occurs more
often than intended?
The severity in which the self-injurious
behaviour occurs has increased
(e.g., deeper cuts, more extensive
parts of your body)?
If the self-injurious behaviour produced
an effect when started, you now need
to self-injure more frequently or with
greater intensity to produce the
same effect?
This behaviour or thinking about it
consumes a significant amount of
your time (e.g., planning and thinking
about it, collecting and hiding sharp
\objects, doing it and recovering from it)?
Despite a desire to cut down or control
this behaviour, you are
unable to do so?
You continue this behaviour despite
recognizing that it is harmful to you
physically and/or emotionally?
Important social, family, academic
or recreational activities are given
up or reduced because of this behaviour?
α .84
Mean scores (SD) 16.22 (6.90)
Table 2 Intercorrelations between the function factors
12 3 4
1. Internal Emotion Regulation - .68*** .90*** -.76***
2. Social Influence - .44*** -.87***
3. External Emotion Regulation - -.59***
4. Sensation Seeking -
Note. *** p < .001
Nixon et al. Child and Adolescent Psychiatry and Mental Health (2015) 9:26 Page 5 of 7
males in clinical populations who engage in NSSI is
required. Third, as this was a secondary analysis of sur-
vey data obtained from a clinical sample, we were unable
to fully explore convergent and discriminant validity
with the data being limited to what was obtained in the
original sample [3].
This current study provides additional support for the
psychometric properties of the OSIs functions and
Addictive Features scales. Further research on larger
clinical and community samples is warranted. Clinicians
can use a self report method that is comprehensive and
validated in an adolescent clinical population. In a recent
study of adolescents with self harm [4], the investigators
found that self repor t was able to detect previously un-
detected NSSI in a clinical setting, suggesting that while
self report questionnaires do not replace clinical assess-
ment, they may enha nce detection rates in youth. While
the purpose of this study was to confirm a preliminary
factor analysis, further research clinically in terms of en-
hancing detection is indicated.
Several recent studies [24, 25] have reviewed treatment
interventions that show promise in youth with NSSI. As
Brent and colleagues [25] emphasize in their summary,
results for both suicide attempts and NSSI should be
reported separately. An assessment tool such as the OSI
could give both baseline and outcome information spe-
cifically on NSSI and its associated functions and fea-
tures. Ougrin and colleagues [24] in their systematic
review and meta analysis of therapeutic interventions for
suicide attempts and self harm in adolescents indicate
that that largest effect sizes are for dialectical behavior
therapy (DBT), cognitive behavioural therapy (CBT) and
mentalization based therapy (MBT), but that no modal-
ity has had its efficacy independently replicated. They
highlight that research is lacking in indentifying variables
that are most important to match youths with NSSI and
their families to inte rventions that may have the most
benefit. With the ability to assess functions based on
four factors (Internal Emotion Regulation, Social Influ-
ence, External Emotion Regulation, and Sensation Seek-
ing) and the extent of Addictive Features, the OSI may
assist in selecting more specific treatment modalities.
For example, for those with the Internal Emotional
Regulation function most highly endorsed, assessment
for mood and anxiety disorders would be important and
the components of DBT and or CBT may be most indi-
cated whe reas those with the Social Influence function
most highly endorsed and related attachment issues
MBT may be more beneficial. For those with significant
Addictive Features endorsed, managing treatment expec-
tations and using a harm reduction approach with
motivational interviewing may be most helpful. More
research in these areas is needed as the treatment of
NSSI in youth continues to lack standardized a ssess -
ment and knowledge about what might be the most
effective treatment s depending on the nature of the
behavior [26].
The OSI can be downloaded free of charge if used for
public institutions and for research purposes at http://
ber_20051.pdf (Additional file 1).
Additional file
Additional file 1: The Ottawa Self-Injury Inventory.
NSSI: Nonsuicidal self-injury; DSM: Diagnostic and Statistical Manual of
Mental Disorders; OSI: Ottawa Self-Injury Inventory; CFA: Confirmatory factor
analysis; SD: Standard deviation; RMSEA: Root Mean Square Error of
Competing interests
The authors declare that they have no competing interests.
Authors contributions
MKN drafted the manuscript, conceived the design and study of secondary
analysis of data from existing clinical sample. CL performed the statistical
analyses and help draft the manuscript. MP conceive d and designed the
original study and help ed draft the manuscript. JV conceived and designed
the original study. PC helped draft and critically edit the manuscript. All
authors read and approved the final manuscript.
Author details
Queen Alexandra Centre for Childrens Health, 2400 Arbutus Rd, Victoria, BC
V8N 1V7, Canada.
University of Ottawa, 136 Jean-Jacques Lussier, Ottawa,
ON K1N 6 N5, Canada.
College of Social and Applied Human Sciences,
University of Guelph, 50 Stone Road East Mackinnon 138, Guelph, ON N1G
2 W1, Canada.
Homewood Health Centre, 150 Delhi St, Guelph, ON N1E
6 K9, Canada.
Mental Health Research, Childrens Hospital of Eastern Ontario,
401 Smyth Rd, Ottawa, ON K1H 8 L1, Canada.
Received: 27 March 2015 Accepted: 10 June 2015
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... Several authors have reviewed the empirical research about self-injury, examining its underlying causes and clinical phenomenology as well as the effects of this behavior on the physiological affective arousal. To date, it is widely thought that there is an emotionregulation function of NSSI, and several research results support the existence of an emotion dysregulation trait among people who engage in this behavior [7][8][9][10][11][12]. Emotional regulation is a multifactorial construct that includes the awareness, understanding and acceptance of emotions, the ability to inhibit impulsive behavior related to emotional distress and the willingness to avoid activities that may trigger negative emotions such as tension, depression or anger. ...
... Nevertheless, it is clear that there are several factors underlying NSSI, which must necessarily be considered as a multifactorial construct. It is therefore necessary to carefully evaluate all of the involved components (clinical, emotional and behavioral) in the initiation and maintenance of self-injurious behaviors, including addictive components and those associated with the most severe NSSI cases, in order to address appropriate treatment options for each subject (such as dialectical and cognitive-behavioral therapy, mentalization and motivation-based approaches and group therapies) [7,12,15]. ...
Full-text available
Non-Suicidal Self-Injury (NSSI) is the self-inflicted destruction of body tissues without suicidal intent with a prevalence of 1.5% to 6.7% in the youth population. At present, it is not clear which emotional and behavioral components are specifically associated with it. Therefore, we studied NSSI in a clinical sample of youth using the Ottawa Self-injury Inventory and the Barratt Impulsiveness Scale 11. The Mann–Whitney test was used to compare the numerical responses provided to the tests. We found 54 patients with NSSI, with a mean age of 17 years. Scores were analyzed in the total sample and in four subgroups. In the total sample, Internal Emotion and External Emotion Regulation, Craving, Non-Planning and Total Impulsivity were significantly associated with NSSI. There were statistically significant differences in Craving between patients with multiple NSSI episodes, suicide attempts and multiple injury modes and patients of other corresponding subgroups, in Internal Emotion Regulation, Sensation Seeking and Motor Impulsivity between NSSI patients with suicide attempts and no suicide attempts, and in Cognitive Impulsivity between NSSI patients with multiple injury modes and one injury mode. It is necessary to carefully evaluate the components underlying NSSI in order to activate personalized treatment options.
... The OSI has displayed good psychometric properties. 63,64 In this study, the scale demonstrated excellent reliability, with a Cronbach's a value of 0.84. ...
Purpose: Sexual minority men (SMM) have been shown to be at high risk of nonsuicidal self-injury (NSSI). Internalized homophobia, body dissatisfaction, and psychological distress have been found to be related to NSSI among SMM, but few studies have focused on the mechanisms underlying these associations. Thus, the current study was conducted to examine the association between internalized homophobia and NSSI, and whether body dissatisfaction and psychological distress mediate this relationship among young SMM in China. Methods: In total, 264 young SMM (mean age, 22.00 – 2.86 years) in Henan Province, China, participated in the study. A set of questionnaires were used to assess participants’ internalized homophobia, body fat dissatisfaction, muscularity dissatisfaction, psychological distress, and NSSI. Correlation and mediation analyses were used to examine the data. Results: Internalized homophobia correlated positively with NSSI (r = 0.24, p < 0.001) among young SMM in China. This relationship was partly mediated by body fat dissatisfaction, muscularity dissatisfaction, and psychological distress. Conclusion: The study findings suggest that internalized homophobia is a risk factor for NSSI among young SMM in China, and that body fat and muscle dissatisfaction and psychological distress underlie the association between internalized homophobia and NSSI. In developing interventions targeting NSSI among SMM, the findings of the current study should be considered to improve intervention outcomes.
... Igualmente se resaltan algunas adaptaciones: SHBQ (USA); SITBI en Alemania; OSI en Alemania, Hungría, Islán y Canadá.(Csorba et al., 2010; Fischer et al., 2014;Muehlenkamp et al., 2010;Nixon et al.;2015;Rodav et al., 2014). En general, la revisión sistemática realizada en este estudio sugiere que muy pocos reportan suficientes evidencias de validez y confiabilidad. ...
Full-text available
Las conductas autolesivas no letales (CAL), son acciones deliberadas para causar daño en el propio cuerpo, ubicándose entre las 10 causas principales de morbilidad en adolescentes. En el año 2020 entre 15 y 30 millones de personas experimentaron CAL; sin embargo, hay pocos instrumentos con óptimas propiedades psicométricas que evalúen adecuadamente el fenómeno. El objetivo fue diseñar y probar las propiedades psicométricas del Cuestionario de Riesgo de Autolesión para adolescentes escolarizados (CRA). Participaron 289 estudiantes, con edades entre los 12 y 16 años (M= 13.42; SD= .82). Se diseñó un cuestionario con 7 dimensiones y 37 ítems; se valoró la consistencia interna, validez de contenido, validez de constructo (análisis factorial exploratorio y confirmatorio) y validez comparada con la Escala de bullying (EBIP-Q). El CRA presentó óptimas propiedades psicométricas para una estructura multifactorial, reconociendo óptimos valores de consistencia interna (α= .96). Se evidenció una correlación directa con la EBIP-Q, corroborando el constructo. Los resultados sugieren que el CRA, diseñado y validado en Colombia, cuenta con adecuada calidad psicométrica; por tanto, es válido y confiable para evaluar el riesgo de realizar conductas autolesivas no letales. Palabras clave: Autolesiones, adolescentes, bullying, autoinjuria.
... Higher scores indicate higher NSSI behaviors frequencies. The OSI has been shown to be valid and reliable in both clinical and non-clinical samples [66,67]. In the present study, we investigated 10 items NSSI behaviors of Chinese college students in the past 12 months and demonstrated reliability with Cronbach's α of 0.94. ...
Full-text available
Objective Extensive evidence from Western societies supports the role for body dissatisfaction in the etiological models of non-suicidal self-injury (NSSI). However, research of the underlying mechanisms of this relationship has been limited, especially in China. Therefore, the aim of this study was to examine the association between body dissatisfaction and NSSI among college students in China. Possible mediating roles for psychological distress and disordered eating, as well as a moderating role for self-compassion, were also examined. Methods College students (n = 655, Mage = 20.32 years, SD = 1.02) were recruited from Henan province, China. Each participant completed questionnaires regarding body dissatisfaction, psychological distress, disordered eating, and self-compassion. Results A close to medium positive relationship between body dissatisfaction and NSSI was revealed with r = 0.24 (p < .001). The relationship was found to be fully mediated by psychological distress and disordered eating. The mediation role for disordered eating was found to be further moderated by self-compassion, suggesting that self-compassion acted as a buffer against the relationship between disordered eating and NSSI. Conclusion These findings indicate that body dissatisfaction, psychological distress, disordered eating, and self-compassion may play important roles in Chinese young adults’ NSSI. Researchers and practitioners need to pay closer attention to the underlying mechanisms of how body dissatisfaction links to NSSI to deepen the understanding of their linkage as well as to provide appropriate interventions. Level of evidence Level V, cross-sectional descriptive study.
... Ottawa Self-injury Questionnaire (OSI) The Ottawa Self-injury Questionnaire (OSI) is a self-assessment questionnaire of 12 questions, assessing the frequency and topicality of self-mutilation, the context of the onset of the behavior, the physical areas involved, and the motivations for this type of behavior [52]. ...
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Background Anorexia nervosa (AN) mainly affects women (sex ratio 1/10) and most often starts during adolescence. The prognosis of AN remains poor (10% of deaths and high risk of chronicity). Body dissatisfaction, disturbances in recognition and identification of body sensations are some of the key symptoms of AN. However, there is a contrast between this consensual observation of body image disorders in AN, and the relative deficit of specifically targeted body treatments. Our proposal for a body approach specifically dedicated to AN is based on the understanding that posture, breathing, muscle tension and body perception are closely linked to our psychological and emotional state and are therefore disturbed in patients with AN. The purpose of this monocentric randomized controlled trial is to evaluate if a targeted osteopathic protocol treatment for AN in addition to treatment as usual (TAU) is significantly more effective than TAU alone. Methods In total, 72 patients meeting the inclusion criteria will be randomly assigned to one of the two treatment groups: one receiving the specific osteopathic treatment targeted for AN in addition to the TAU (group A) and the other one, receiving TAU only (group B). The patients in group A will receive 5 30-min osteopathic treatment sessions. Soft specific palpatory techniques on the diaphragm, digestive system and cervical region will be performed. The TAU is defined by the multidisciplinary approach recommended by the French health high authority. The primary outcome is the evaluation of interoceptive sensibility and secondary outcomes include clinical and psychopathology-related symptoms with assessment of somatic dysfunctions’ evolution. A qualitative study will also be carried out, applying the Interpretative Phenomenological Analysis method. Patients will be included for a maximum of 14 weeks between the inclusion time and the last evaluation. Discussion If the results of the study are positive (statistically significant efficacy of this osteopathic treatment protocol), the study will provide arguments in favor of osteopathic sessions as a possible non-invasive additional treatment option in the multidisciplinary care approach for patients with AN. Trial registration ID: NCT04666415, Release Date: December 11, 2020; N° ID-RCB: 2019-A02613-54.
... This scale is one of the most comprehensive scales as it assesses all characteristic domains of self-injury, as well as evaluating the addictive features, motivation to stop engaging in the behavior, effectiveness of the self-injury in achieving the reported functions, response for continuing to self-injure, and the current functions served by the most recent act of self-injury. The IOS has shown strong validity and reliability (Nixon et al., 2015). ...
Full-text available
Self-injurious behaviors affect millions of adolescents each year, indicating a public health problem needing attention and intervention. Non-suicidal self-injury (NSSI) is the act of purposefully hurting oneself without the conscious intent to die, such as self-cutting, burning, or carving. As the rate of engagement in NSSI is growing among adolescents, mental health practitioners are increasingly faced with responding to NSSI behaviors among adolescent clients. These mental health practitioners must adequately and efficiently identify the behaviors and determine the course of treatment to best support the client and reduce the NSSI behaviors. This article aims to educate practitioners around NSSI behaviors, assessment techniques, and the current evidence-based interventions available to treat adolescents who struggle with NSSI to determine the best practice for this high-risk population by using a case example. Due to the lack of research on NSSI, there is a significant gap in knowledge related to interventions for adolescents who engage in NSSI. Practitioners often report having little training specific to the issues and needs of adolescents who engage in NSSI.
Background & Aims Previous studies have shown that nonsuicidal self-injury (NSSI) has addictive features, and an addiction model of NSSI has been considered. Addictive features have been associated with severity of NSSI and adverse psychological experiences. Yet, there is debate over the extent to which NSSI and substance use disorders (SUDs) are similar experientially. Methods To evaluate the extent that people who self-injure experience NSSI like an addiction, we coded the posts of users of the subreddit r/selfharm ( n = 500) for each of 11 DSM-5 SUD criteria adapted to NSSI. Results A majority (76.8%) of users endorsed at least two adapted SUD criteria in their posts, indicative of mild, moderate, or severe addiction. The most frequently endorsed criteria were urges or cravings (67.6%), escalating severity or tolerance (46.7%), and NSSI that is particularly hazardous. User-level addictive features positively predicted number of methods used for NSSI, number of psychiatric disorders, and particularly hazardous NSSI, but not suicidality. We also observed frequent use of language and concepts common in SUD recovery circles like Alcoholics Anonymous. Discussion & Conclusion Our findings support previous work describing the addiction potential of NSSI and associating addictive features with clinical severity. These results suggest that NSSI and SUD may share experiential similarities, which has implications for the treatment of NSSI. We also contribute to a growing body of work that uses social media as a window into the subjective experiences of stigmatized populations.
Parental psychological control has been shown to be associated with adolescent non-suicidal self-injury (NSSI). However, little is known about the mediating and moderating mechanisms underlying this relationship. Self-determination theory and previous research provided the framework for our hypotheses about these processes. This study test the mediating effect of psychological need satisfaction between parental psychological control and adolescent NSSI, and whether this mediating effect was moderated by sensation seeking. A sample of 1006 adolescents (Mage = 13.16 years; SD = 0.67 years) anonymously completed questionnaires assessing the study variables. The results of structural equation modeling showed that as expected, the positive association between parental psychological control and adolescent NSSI was mediated by low satisfaction of the psychological needs. Also as expected, this indirect link was stronger among adolescents high in sensation seeking. The results are consistent with the self-determination theory’s assumption that psychological need satisfaction as a potential mechanism linking parental psychological control to adolescent NSSI, and high sensation seeking as an important risk factor that amplifies this indirect effect. Intervention programs aimed at reducing adolescent NSSI may benefit from this study, such as Dialectical Behavior Therapy.
Background The high prevalence of nonsuicidal self-injury (NSSI) in youths demonstrates a substantial population-level burden on society. NSSI is often associated with emotional and social skill deficits. To date, several studies have aimed to identify the underlying neural mechanism of those deficits in NSSI by using functional magnetic resonance imaging (fMRI). However, their conclusions display poor consistency. Objective We aimed to conduct a meta-analysis using activation likelihood estimation (ALE) for fMRI data based on emotional and cognitive tasks to clarify the underlying neural processing deficits of NSSI. Methods We searched for MRI studies of NSSI in the PubMed, Cochrane, and Embase databases. We identified significant foci for the included studies and conducted two ALE meta-analyses as follows: (i) activation for the NSSI contrast healthy control group and (ii) deactivation for the NSSI contrast healthy controls. Considering the diverse sex composition of study participants and possible bias from one large sample study, we conducted sensitivity analyses for the meta-analysis. Results Nine studies comprising 359 participants were included, and the results demonstrated substantial activation in NSSI patients compared with healthy controls in two clusters located in the right medial frontal gyrus extending to the rostral anterior cingulate and the left inferior frontal gyrus extending to the insula. Conclusions The results suggest that individuals with NSSI show brain activity alterations that underpin their core symptoms, including poor emotional regulation and reward processing deficits. Our findings provide new insights into the neural mechanism of NSSI, which may serve as functional biomarkers for developing effective diagnosis and therapeutic interventions for these patients.
Adolescents and emerging adults who engage in nonsuicidal self-injury (NSSI) often participate in online activity regarding their self-injury. Of particular importance are the potential benefits and risks associated with online NSSI activity, including how individuals describe their NSSI experiences. One way that individuals describe these experiences is by discussing NSSI as an addiction. Accordingly, we used thematic analysis to explore why individuals may use addiction references to describe their NSSI experiences. To do this, we examined 71 posts from a popular NSSI social network. Four themes emerged: difficulty inherent in stopping, authentication, warn others, and communicate the plight of the behavior. Findings highlight a number of avenues for research as well as implications for clinicians working with clients who self-injure perceive NSSI as an addiction. Mental health professionals can leverage their understanding of clients' perceptions of NSSI to better serve this population.
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Nonsuicidal self-injury (NSSI) is an issue primarily of concern in adolescents and young adults. Thus far, no single NSSI self-report measure offers a fully comprehensive assessment of NSSI, particularly including measurement of both its functions and potential addictive features. The Ottawa Self-Injury Inventory (OSI) permits simultaneous assessment of both these characteristics; the current study examined the psychometric properties of this measure in a sample of 149 young adults in a university student sample (82.6% girls, Mage = 19.43 years). Exploratory factor analyses revealed 4 functions factors (internal emotion regulation, social influence, external emotion regulation, and sensation seeking) and a single addictive features factor. Convergent evidence for the functions factor scores was demonstrated through significant correlations with an existing measure of NSSI functions and indicators of psychological well-being, risky behaviors, and context and frequency of NSSI behaviors. Convergent evidence was also shown for the addictive features scores, through associations with NSSI frequency, feeling relieved following NSSI, and inability to resist NSSI urges. Additional comment is made regarding the potential for addictive features of NSSI to be both negatively and positively reinforcing. Results show preliminary psychometric support for the OSI as a valid and reliable assessment tool to be used in both research and clinical contexts. The OSI can provide important information for case formulation and treatment planning, given the comprehensive and all-inclusive nature of its assessment capacities. (PsycINFO Database Record (c) 2013 APA, all rights reserved).
Suicidal behavior and self-harm are common in adolescents and are associated with elevated psychopathology, risk of suicide, and demand for clinical services. Despite recent advances in the understanding and treatment of self-harm and links between self-harm and suicide and risk of suicide attempt, progress in reducing suicide death rates has been elusive, with no substantive reduction in suicide death rates over the past 60 years. Extending prior reviews of the literature on treatments for suicidal behavior and repetitive self-harm in youth, this article provides a meta-analysis of randomized controlled trials (RCTs) reporting efficacy of specific pharmacological, social, or psychological therapeutic interventions (TIs) in reducing both suicidal and non-suicidal self-harm in adolescents.Method Data sources were identified by searching the Cochrane, Medline, PsychINFO, EMBASE, and PubMed databases as of May 2014. RCTs comparing specific therapeutic interventions versus treatment as usual (TAU) or placebo in adolescents (through age 18) with self-harm were included.Results19 RCTs including 2,176 youth were analyzed. TIs included psychological and social interventions and no pharmacological interventions. The proportion of the adolescents who self-harmed over the follow-up period was lower in the intervention groups (28%) than in controls (33%), test for overall effect Z=2.31 (p=0.02). TIs with biggest effect sizes were dialectical behavior therapy (DBT), cognitive-behavioral therapy (CBT), and mentalization-based therapy (MBT). There were no independent replications of efficacy of any TI. The pooled risk difference between TIs and TAU for suicide attempts and non-suicidal self-harm considered separately was not statistically significant.ConclusionTIs to prevent self-harm appear to be effective. Independent replication of the results achieved by DBT, MBT, and CBT is a research priority.
Introduction: The purpose of this study was to explore the prevalence of self-harm and the psychosocial factors associated with self-harming behaviours in youth admitted to an in-patient psychiatric unit. Methods: Cross-sectional surveys of standardized measures were administered to youth and a separate survey to their caregivers while the youth were in hospital. Results: The mean age of the 123 youth who participated was 15.74 (SD 1.51) years, and 90 of 121 (74.38%) reported being female. Of the 115 who completed this question, 101 (87.83%) indicated that they thought of injuring themselves and 89 (77.39%) did engage in NSSI within the past month, and 78 of 116 (67%) reported that they had made an attempt to take their life. Youth who reported that they had attempted suicide (lifetime) reported significantly less difficulty with emotion regulation than youth who engaged in NSSI only, or both NSSI and suicide attempts. Conclusions: These youth reported a very high prevalence of self-harm, and in general substantial difficulty with regulating their emotions, and difficulty with their interpersonal relationships. The psychosocial distinctions evident between groups may have practical utility.
To review the studies that test treatments targeting adolescent suicidal ideation, suicide attempts, or self-harm, and to make recommendations for future intervention development. The extant randomized clinical trials that aim to reduce the intensity of suicidal ideation or the recurrence of suicide attempts or self-harm were reviewed with respect to treatment components, comparison treatments, sample composition, and outcomes. The majority of studies that showed any effect on suicidal ideation, attempts, or self-harm had some focus on family interactions or nonfamilial sources of support. Two of the most efficacious interventions also provided the greatest number of sessions. Some other treatment elements associated with positive effects include addressing motivation for treatment and having explicit plans for integrating the experimental treatment with treatment as usual. In many studies, suicidal events tend to occur very early in the course of treatment prior to when an effective "dose" of treatment could be delivered. Important factors that might mitigate suicidal risk, such as sobriety, healthy sleep, and promotion of positive affect, were not addressed in most studies. Interventions that can front-load treatment shortly after the suicidal crisis, for example, while adolescent suicide attempters are hospitalized, may avert early suicidal events. Treatments that focus on the augmentation of protective factors, such as parent support and positive affect, as well as the promotion of sobriety and healthy sleep, may be beneficial with regard to the prevention of recurrent suicidal ideation, attempts, or self-harm in adolescents.