The Relation between Theory of Mind and Nonsuicidal Self-Injury
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Nonsuicidal self-injury (NSSI), defined as deliberate bodily harm without intent to die, is at epidemic-level proportions in adolescent populations ( Muehlenkamp, Claes, Havertape, & Plener, 2012; Nock, Joiner, Gordon, Lloyd-Richardson, & Prinstein, 2006). Associated with a variety of negative risks/consequences (accidental death, body image issues, permanent scarring, stigmatization), NSSI represents a major public health concern, with estimated costs of self-inflicted injury at $33 billion (Corso, Mercy, Simon, Finkelstein, & Miller, 2007). Previously, NSSI has been related to interpersonal functioning, with well-documented links between social processes and self-injurious behaviors (Muehlenkamp, Brausch, Quigley, & Whitlock, 2013; Nock & Mendes, 2008; Prinstein et al., 2010). One such interpersonal process is social cognition. In adults, NSSI has been significantly related to abnormalities in general social cognitive abilities (i.e., interpretations of social interactions; Whipple & Fowler, 2011). Theory of mind (ToM), which refers to one’s ability to attribute mental states to the self and others (Sharp et al., 2011), has been implicated as a social-cognitive process related to NSSI, with treatment-based research (Rossouw & Fonagy, 2012) finding that interventions focused on ToM (i.e., Mentalization-Based Treatment) reduce adolescent self-harm behavior. Despite intervention-based research, empirical work has yet to directly investigate the relation between ToM and NSSI in adolescent inpatients, a subset where NSSI remains prevalent and medically severe. Against this background, the present study aimed to examine the relation between ToM and NSSI in a high-risk adolescent inpatient sample. Moreover, specific aims of the present study were: (a) to examine the relation between ToM impairment and behavioral characteristics of NSSI (lifetime frequency, medical severity), and (b) to examine the relation between ToM impairment and NSSI functions. N=63 adolescent inpatient self-injurers admitted to a private, residential inpatient unit were recruited for the current sample. ToM was assessed using a computerized experimental task and NSSI with semi-structured interviews and self-report based measures. First, correlational analyses were used to examine the relation between ToM, NSSI behavioral characteristics (frequency, severity), and confounds (depressive symptoms, age, gender, race). No significant relations were found between ToM impairment and behavioral characteristics for NSSI. Second, we examined bivariate and regression analyses between ToM impairment, NSSI functions (13 individual function subscales loading onto two sub-domains: intrapersonal, interpersonal), and all aforementioned confounds. Regarding NSSI functions, ToM impairment was significantly related to overall endorsement of interpersonal, or socially-regulated, functions for NSSI, particularly toughness and autonomy, and this was unique from ToM impairment’s null relation to intrapersonal functions for NSSI. Regression analyses revealed the ToM-interpersonal NSSI function related exists above and beyond the effects of depression, and is not moderated by gender. Findings overall suggest that, although intrapersonal functions (i.e., self-regulated) functions for NSSI are most commonly endorsed among adolescent inpatients, impairments in an adolescent’s ability to attribute, interpret, and understand the mental states and emotions of others are what appear to relate to interpersonally-focused functions for NSSI. Findings on the ToM-NSSI functionality relation point to the efficacy and importance of utilizing emotion-focused (i.e., Dialectical Behavior Therapy) and social-cognitive treatments (i.e., Mentalization Based Treatment) for adolescent self-injurers in acute care settings.