Towards a better understanding of non-suicidal self-injury (NSSI) in college students: Predictive factors, triggering mechanisms and potential life-threatening repercussions.
Non-suicidal self-injury (NSSI) is posing significant public health challenges among young people. While an increasing subpopulation of young people in today’s society consists of college students, there is limited knowledge of the prevalence and course, risk estimation, and significance of NSSI for college mental health. This doctoral project describes six empirical studies that were conducted to provide a better understanding of NSSI among college students.
In the first study, with a sample of 20,842 first-year college students from 9 countries, the pooled prevalence of lifetime, 12-month NSSI, and positive screen for DSM-5 NSSI disorder was estimated at 17.7%, 8.4%, and 2.3%, respectively. Findings further revealed that the association between NSSI and mental disorders is likely reciprocal, with the presence of a mental disorder being associated with the subsequent onset of NSSI, and NSSI also predicting future mental disorders. A second study revealed that only a small subgroup (0.8%) of students meets full diagnostic criteria for NSSI disorder. While we observed that students diagnosed with the proposed disorder report a high level of comorbid mental disorders, NSSI disorder remained associated with severe role impairment in daily life when controlling for the presence of mental disorders. In the third study, we evaluated the extent to which NSSI is associated with increased risk of suicidal thoughts and behaviors, over and above the effect of mental disorders. Findings revealed that NSSI is uniquely associated with increased risk for subsequent suicide attempt (on average three years later), as well as suicide ideation and suicide plans. Further analyses also linked NSSI to key transitions between suicidal ideation and suicide attempt, including (1) transitioning from ideation to developing a plan and (2) transitioning from having a plan to making an attempt. Those who engaged in repetitive and severe NSSI were most likely to attempt suicide.
In the fourth study, we estimated the incidence of NSSI at 10.3% in year 1 and 6.0% in year 2 of college, with 7.0% of students reporting repetitive NSSI (≥ 5 times per year) for the first time during the college period. A range of distal and proximal risk factors (i.e., childhood or adolescent trauma, 12-month stressors, and mental disorders) were prospectively associated with the onset of NSSI, and combining these into an integrative prediction model enabled us to accurately detect college entrants at high cumulative risk for incident NSSI. In the fifth study, we found that NSSI severity indicators (e.g., higher lifetime frequency) differentiated college students who continue to self-injure from those that cease NSSI during the college period. We also observed that emotional distress had no significant effect beyond perceived emotion regulatory capability, which was uniquely related to NSSI cessation. Finally, in a sixth study we explored short-term predictors of NSSI thoughts and behaviors in daily life. Using assessments up to eight times per day from students who engage in NSSI revealed that NSSI thoughts occurred in situations with high momentary levels of negative affect and low levels of positive affect. Acute risk of NSSI behavior was elevated in these situations when students perceived low ability to resist NSSI.
Taken together, these findings indicate that NSSI is relatively prevalent among college students, although few meet diagnostic criteria for NSSI disorder. In light of these findings, we recommend that researchers evaluate the potential of a stepped-care approach in responding to NSSI on college campuses. Importantly, our findings highlight the feasibility of incorporating prevention into such a framework as we demonstrated the potential of web-based risk-screening for detecting students at high risk of new-onset NSSI. Counselors and academic staff should take NSSI seriously in order to avoid the development or a further escalation of suicidal thoughts and behavior. For policymakers, our data indicate that providing timely and effective interventions for young people who engage in NSSI might be one fruitful strategy to prevent significant future impairment and loss of life. Future studies in this area, as well as research that develops personalized prediction models for acute risk of NSSI, have the potential to deliver cost-effective tools for the prevention and intervention of NSSI among college students.