Nonsuicidal Self-Injury as a Gateway to Suicide in Young Adults



      To investigate the extent to which nonsuicidal self-injury (NSSI) contributes to later suicide thoughts and behaviors (STB) independent of shared risk factors.


      One thousand four hundred and sixty-six students at five U.S. colleges participated in a longitudinal study of the relationship between NSSI and suicide. NSSI, suicide history, and common risk/protective factors were assessed annually for three years. Analyses tested the hypotheses that the practice of NSSI prior to STB and suicide behavior (excluding ideation) reduced inhibition to later STB independent of shared risk factors. Analyses also examined factors that predicted subsequent STB among individuals with NSSI history.


      History of NSSI did significantly predict concurrent or later STB (AOR 2.8, 95%, CI 1.9–4.1) independent of covariates common to both. Among those with prior or concurrent NSSI, risk of STB is predicted by > 20 lifetime NSSI incidents (AOR 3.8, 95% CI, 1.4–10.3) and history of mental health treatment (AOR 2.2, 95% CI, 1.9–4.6). Risk of moving from NSSI to STB is decreased by presence of meaning in life (AOR .6, 95% CI, .5–.7) and reporting parents as confidants (AOR, .3, 95% CI, .1–.9).


      NSSI prior to suicide behavior serves as a “gateway” behavior for suicide and may reduce inhibition through habituation to self-injury. Treatments focusing on enhancing perceived meaning in life and building positive relationships with others, particularly parents, may be particularly effective in reducing suicide risk among youth with a history of NSSI.


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      1. International Society for the Study of Self-injury. Definitional issues surrounding our understanding of self-injury. 2007.

        • Kaminski J.
        • Puddy R.
        • Hall D.
        • et al.
        The relative influence of different domains of social connectedness on self-directed violence in adolescence.
        J Youth Adolesc. 2010; 39: 460-473
        • Whitlock J.
        • Knox K.L.
        The relationship between self-injurious behavior and suicide in a young adult population.
        Arch Pediatr Adolesc Med. 2007; 161: 634-640
        • Muehlenkamp J.
        • Gutierrez P.M.
        Risk for suicide attempts among adolescents who engage in non-suicidal self-injury.
        Arch Suicide Res. 2007; 11: 69-82
        • Andover M.S.
        • Gibb B.E.
        Non-suicidal self-injury, attempted suicide, and suicidal intent among psychiatric inpatients.
        Psychiatry Res. 2010; 178: 101-105
        • Nock M.K.
        • Joiner T.E.
        • Gordon K.H.
        • et al.
        Non-suicidal self-injury among adolescents: Diagnostic correlates and relation to suicide attempts.
        Psychiatry Res. 2006; 144: 65-72
        • Brausch A.M.
        • Gutierrez P.M.
        Differences in non-suicidal self-injury and suicide attempts in adolescents.
        J Youth Adolesc. 2010; 39: 233-242
        • Plener P.L.
        • Keller F.
        • Fegert J.M.
        • et al.
        An international comparison of adolescent non-suicidal self-injury (NSSI) and suicide attempts: Germany and the USA.
        Psychol Med. 2009; 39: 1549-1558
        • Wilkinson P.O.
        Nonsuicidal self-injury: A clear marker for suicide risk.
        J Am Acad Child Adolesc Psychiatry. 2011; 50: 741-743
        • Wilkinson P.
        • Kelvin R.
        • Roberts C.
        • et al.
        Clinical and psychosocial predictors of suicide attempts and nonsuicidal self-injury in the adolescent depression antidepressants and psychotherapy trial (ADAPT).
        Am J Psychiatry. 2011; 168: 495-501
      2. Wichstrom L. Predictors of non-suicidal self-injury versus attempted suicide: Similar or different? Arch Suicide Res 13:105–122.

        • Joiner T.E.
        Why people die by suicide.
        Harvard University Press, Cambridge, MA2006
        • Gratz K.
        Measurement of deliberate self-harm: Preliminary data on the deliberate self-harm inventory.
        J Psychopathol Behav Assess. 2001; 23: 253-263
        • Nock M.K.
        • Mendes W.B.
        Physiological arousal, distress tolerance, and social problem-solving deficits among adolescent self-injurers.
        J Consult Clin Psychol. 2008; 76: 28-38
        • Baetens I.
        • Claes L.
        • Onghena P.
        • et al.
        Non-suicidal and suicidal self-injurious behavior among Flemish adolescents: A web-survey.
        Arch Suicide Res. 2011; 15: 56-67
        • Nixon M.K.
        • Cloutier P.
        • Jansson S.M.
        Nonsuicidal self-harm in youth: A population-based survey.
        CMAJ. 2008; 178: 306-312
        • Whitlock J.
        • Eckenrode J.
        • Silverman D.
        Self-injurious behaviors in a college population.
        Pediatrics. 2006; 117: 1939-1948
        • Claes L.
        • Houben A.
        • Vandereycken W.
        • et al.
        Brief report: The association between non-suicidal self-injury, self-concept and acquaintance with self-injurious peers in a sample of adolescents.
        J Adolesc. 2010; 33: 775-778
        • Jacobson C.
        • Muehlenkamp J.
        • Miller A.
        • Turner J.B.
        Psychiatric impairment among adolescents engaging in different types of deliberate self-harm.
        J Clin Child Adolesc Psychol. 2008; 37: 363-375
        • Klonsky E.D.
        • Moyer A.
        Childhood sexual abuse and non-suicidal self-injury: Meta-analysis.
        Br J Psychiatry. 2008; 192: 166-170
        • Muehlenkamp J.J.
        • Kerr P.L.
        • Bradley A.R.
        • Adams Larsen M.
        Abuse subtypes and nonsuicidal self-injury: Preliminary evidence of complex emotion regulation patterns.
        J Nerv Ment Dis. 2010; 198: 258-263
        • Stone L.B.
        • Gibb B.E.
        • Hankin B.L.
        • Abela J.R.Z.
        J Abnorm Psychol. 2011; 120: 752-757
        • Hankin B.L.
        • Stone L.
        • Wright P.A.
        Dev and Psychopathol. 2010; 22: 217-235
      3. Whitlock J, Purington A. Validity and reliability of the non-suicidal self-injury assessment tool (NSSI-AT): Why use the NSSI-AT? Poster presented at: 6th Annual Meeting of the International Society for the Study of Self-Injury; June 2011; New York, NY.

        • Whitlock J.
        • Muehlenkamp J.
        • Purington A.
        • et al.
        Non-suicidal self-injury in a college population: General trends and sex differences.
        J Am Coll Health. 2011; 59: 691-698
        • Cheng H.
        • Mallinckrodt B.
        • Soet J.
        • Sevig T.
        Developing a screening instrument and at-risk profile for nonsuicidal self-injurious behavior in college women and men.
        J Counseling Psychol. 2010; 57: 128-139
        • Kessler R.C.
        • Berglund P.
        • Borges G.
        • et al.
        Trends in suicide ideation, plans, gestures, and attempts in the United States, 1990–1992 to 2001–2003.
        JAMA. 2005; 293: 2487-2495
        • Herzberg P.Y.
        • Glaesmer H.
        • Hoyer J.
        Separating optimism and pessimism: A robust psychometric analysis of the revised life orientation test (LOT-R).
        Psychological Assess. 2006; 18: 433-438
        • Gratz K.
        • Roemer L.
        Multidimensional assessment of emotion regulation and dysregulation: Development, factor structure, and initial validation of the difficulties in emotion regulation scale.
        J Psychopathol Behav Assess. 2004; 26: 41-54
        • Steger M.F.
        • Frazier P.
        • Oishi S.
        • Kaler M.
        The meaning in life questionnaire: Assessing the presence of and search for meaning in life.
        J Counseling Psychol. 2006; 53: 80-93
        • Hughes M.E.
        • Waite L.J.
        • Hawkley L.C.
        • Cacioppo J.T.
        A short scale for measuring loneliness in large surveys: Results from two population-based studies.
        Res Aging. 2004; 26: 655-672
        • Caspi A.
        • Moffitt T.E.
        • Thornton A.
        • et al.
        The life history calendar: A research and clinical assessment method for collecting retrospective event-history data.
        Int J Methods Psychiatr Res. 1996; 6: 101-114
        • Kessler R.C.
        • Andrews G.
        • Colpe L.J.
        • et al.
        Short screening scales to monitor population prevalences and trends in non-specific psychological distress.
        Psychological Med. 2002; 32: 959-976
        • IBM SPSS
        Statistics [computer program]. Version 19.0.
        SPSS, Inc, 2010
        • Allison P.D.
        Discrete-time methods for the analysis of event histories.
        Sociol Methodology. 1982; 13: 61-98
        • Skegg K.
        Lancet. 2005; 366: 1471-1483