Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

  • Article
  • Published:

A meta-analysis on the affect regulation function of real-time self-injurious thoughts and behaviours

Nature Human Behaviour volume 6, pages 964–974 (2022)Cite this article

Subjects

Abstract

Prominent theories suggest that self-injurious thoughts and behaviours are negatively reinforced by decreased negative affect. The present meta-analysis quantifies effects from intensive longitudinal studies measuring negative affect and self-injurious thoughts and behaviours. We obtained data from 38 of the 79 studies (48%, 22 unique datasets) involving N = 1,644 participants (80% female, 75% white). Individual-participant data meta-analyses revealed changes in affect pre/post self-injurious thoughts and behaviours. In antecedent models, results supported increased negative affect before nonsuicidal self-injurious behaviour (k = 14, 95% CI 0.09 to 0.31) and suicidal thoughts (k = 14, 95% CI 0.03 to 0.19). For consequence models, negative affect was reduced following nonsuicidal self-injurious thoughts (k = 6, 95% CI −0.79 to −0.44), nonsuicidal self-injurious behaviours (k = 14, 95% CI −0.73 to −0.19) and suicidal thoughts (k = 13, 95% CI −0.79 to −0.23). Findings, which were not moderated by sampling strategies or sample composition, support the affect regulation function of self-injurious thoughts and behaviours.

This is a preview of subscription content, access via your institution

Access options

Buy this article

  • Purchase on Springer Link
  • Instant access to full article PDF
Buy now

Prices may be subject to local taxes which are calculated during checkout

Fig. 1: CONSORT flow diagram.
Fig. 2: Forest plots of NSSI behaviours in both antecedent and consequence models.
Fig. 3: Forest plots of suicidal thoughts in both antecedent and consequence models.

Similar content being viewed by others

Data availability

Although this study was not preregistered, the raw data are publicly available at https://github.com/kskuehn/NA-SITB_meta.

Code availability

Analysis scripts are also publicly available at https://github.com/kskuehn/NA-SITB_meta.

References

  1. Suicide rate estimates, age-standardized estimates by WHO region. Global Health Observatory Data Repository, World Health Organization https://apps.who.int/gho/data/node.main.MHSUICIDEASDR?lang=en (2021).

  2. Substance Abuse and Mental Health Services Administration. Key substance use and mental health indicators in the United States: results from the 2019 national survey on drug use and health (HHS publication no. PEP20-07-01-001, NSDUH Series H-55). Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration https://www.samhsa.gov/data/ (2020).

  3. Nock, M. K. Self-injury. Annu. Rev. Clin. Psychol. 6, 339–363 (2010).

    Article  PubMed  Google Scholar 

  4. Whitlock, J. et al. Nonsuicidal self-injury as a gateway to suicide in young adults. J. Adolesc. Health 52, 486–492 (2010).

    Article  Google Scholar 

  5. Gillies, D. et al. Prevalence and characteristics of self-harm in adolescents: meta-analyses of community-based studies 1990–2015. J. Am. Acad. Child Adolesc. Psychiatry 57, 733–741 (2018).

    Article  PubMed  Google Scholar 

  6. Franklin, J. C. et al. Risk factors for suicidal thoughts and behaviors: a meta-analysis of 50 years of research. Psychol. Bull. 143, 187–232 (2017).

    Article  PubMed  Google Scholar 

  7. Nock, M. K. & Prinstein, M. J. A functional approach to the assessment of self-mutilative behavior. J. Consult. Clin. Psychol. 72, 885–890 (2004).

    Article  PubMed  Google Scholar 

  8. Chapman, A. L., Gratz, K. L. & Brown, M. Z. Solving the puzzle of deliberate self-harm: the experiential avoidance model. Behav. Res. Ther. 44, 371–394 (2006).

    Article  PubMed  Google Scholar 

  9. Kleiman, E. M. et al. Are suicidal thoughts reinforcing? A preliminary real-time monitoring study on the potential affect regulation function of suicidal thinking. J. Affect. Disord. 232, 122–126 (2018).

    Article  PubMed  Google Scholar 

  10. Berking, M. & Lukas, C. A. The affect regulation training (ART): a transdiagnostic approach to the prevention and treatment of mental disorders. Curr. Opin. Psychol. 3, 64–69 (2015).

    Article  Google Scholar 

  11. Levitt, J. T. & Cloitre, M. A clinician’s guide to STAIR/MPE: treatment for PTSD related to childhood abuse. Cogn. Behav. Pract. 12, 40–52 (2005).

    Article  Google Scholar 

  12. Linehan, M. M. Cognitive-Behavioral Treatment of Borderline Personality Disorder (Guilford Press, 1993).

  13. Stasiewicz, P. R. et al. Affect regulation training (ART) for alcohol use disorders: development of a novel intervention for negative affect drinkers. J. Subst. Abus. Treat. 45, 433–443 (2013).

    Article  Google Scholar 

  14. Neacsiu, A. D., Bohus, M. & Linehan, M. M. in Handbook of Emotion Regulation (ed. Gross, J. J.) 491–507 (Guilford Press, 2014).

  15. Taylor, P. J. et al. A meta-analysis of the prevalence of different functions of non-suicidal self-injury. J. Affect. Disord. 227, 759–769 (2018).

    Article  PubMed  Google Scholar 

  16. Littlefield, A. K., Talley, A. E. & Jackson, K. M. Coping motives, negative moods, and time-to-drink: exploring alternative analytic models of coping motives as a moderator of daily mood-drinking covariation. Addict. Behav. 37, 1371–1376 (2012).

    Article  PubMed  PubMed Central  Google Scholar 

  17. Bradburn, N. M., Rips, L. J. & Shevell, S. K. Answering autobiographical questions: the impact of memory and inference on surveys. Science 236, 157–161 (1987).

    Article  CAS  PubMed  Google Scholar 

  18. Eysenck, M. W. & Mogg, K. in The Handbook of Emotion and Memory: Research and Theory (ed. Christianson, S. A.) 429–450 (Psychology Press, 1992).

  19. Blyth, C. R. On Simpson’s paradox and the sure-thing principle. J. Am. Stat. Assoc. 67, 364–366 (1972).

    Article  Google Scholar 

  20. Curran, P. J. & Bauer, D. J. The disaggregation of within-person and between-person effects in longitudinal models of change. Annu. Rev. Psychol. 62, 583–619 (2011).

    Article  PubMed  PubMed Central  Google Scholar 

  21. Reitz, S. et al. Incision and stress regulation in borderline personality disorder: neurobiological mechanisms of self-injurious behaviour. Br. J. Psychiatry 207, 165–172 (2015).

    Article  PubMed  Google Scholar 

  22. Welch, S. S., Linehan, M. M., Sylvers, P., Chittams, J. & Rizvi, S. L. Emotional responses to self-injury imagery among adults with borderline personality disorder. J. Consult. Clin. Psychol. 76, 45–51 (2008).

    Article  PubMed  Google Scholar 

  23. Franklin, J. C. et al. The functions of nonsuicidal self-injury: support for cognitive–affective regulation and opponent processes from a novel psychophysiological paradigm. J. Abnorm. Psychol. 119, 850–862 (2008).

    Article  Google Scholar 

  24. Kleiman, E. M. & Nock, M. K. Real-time assessment of suicidal thoughts and behaviors. Curr. Opin. Psychol. 22, 33–37 (2018).

    Article  PubMed  Google Scholar 

  25. Kiekens, G., Robinson, K., Tatnell, R. & Kirtley, O. J. Opening the black box of daily life in nonsuicidal self-injury research: with great opportunity comes great responsibility. JMIR Ment. Health 8, e30915 (2021).

    Article  PubMed  PubMed Central  Google Scholar 

  26. Kleiman, E. M. et al. Digital phenotyping of suicidal thoughts. Depress. Anxiety 35, 601–608 (2018).

    Article  PubMed  Google Scholar 

  27. King, K. M. et al. Longitudinal modeling in developmental neuroimaging research: common challenges, and solutions from developmental psychology. Dev. Cogn. Neurosci. 33, 54–72 (2018).

    Article  PubMed  Google Scholar 

  28. Armey, M. F., Crowther, J. H. & Miller, I. W. Changes in ecological momentary assessment reported affect associated with episodes of nonsuicidal self-injury. Behav. Ther. 42, 579–588 (2011).

    Article  PubMed  Google Scholar 

  29. Bresin, K., Carter, D. L. & Gordon, K. H. The relationship between trait impulsivity, negative affective states, and urge for nonsuicidal self-injury: a daily diary study. Psychiatry Res. 205, 227–231 (2013).

    Article  PubMed  Google Scholar 

  30. Kiekens, G. et al. Fluctuations in affective states and self-efficacy to resist non-suicidal self-injury as real-time predictors of non-suicidal self-injurious thoughts and behaviors. Front. Psychiatry 11, 214 (2020).

    Article  PubMed  PubMed Central  Google Scholar 

  31. Borenstein, M., Hedges, L. V., Higgins, J. P. T. & Rothstein, H. R. Introduction to Meta-Analysis (Wiley, 2021).

  32. Friedman, L. Why vote-count reviews don’t count. Biol. Psychiatry 49, 161–162 (2001).

    Article  Google Scholar 

  33. Hamza, C. A. & Willoughby, T. Nonsuicidal self‐injury and affect regulation: recent findings from experimental and ecological momentary assessment studies and future directions. J. Clin. Psychol. 71, 561–574 (2015).

    Article  PubMed  Google Scholar 

  34. Hepp, J. et al. A systematic review of daily life studies on non-suicidal self-injury based on the four-function model. Clin. Psychol. Rev. 82, 101888 (2020).

    Article  PubMed  PubMed Central  Google Scholar 

  35. Rodríguez-Blanco, L., Carballo, J. J. & Baca-Garcia, E. Use of ecological momentary assessment (EMA) in non-suicidal self-injury (NSSI): a systematic review. Psychiatry Res. 263, 212–219 (2018).

    Article  PubMed  Google Scholar 

  36. Sedano-Capdevila, A., Porras-Segovia, A., Bello, H. J., Baca-García, E. & Barrigon, M. L. Use of ecological momentary assessment to study suicidal thoughts and behavior: a systematic review. Curr. Psychiatry Rep. 23, 1–17 (2021).

    Article  Google Scholar 

  37. Gee, B. L., Han, J., Benassi, H. & Batterham, P. J. Suicidal thoughts, suicidal behaviours and self-harm in daily life: a systematic review of ecological momentary assessment studies. Digital Health 6, 2055207620963958 (2020).

    Article  PubMed  PubMed Central  Google Scholar 

  38. Rabasco, A. & Sheehan, K. The use of intensive longitudinal methods in research on suicidal thoughts and behaviors: a systematic review. Arch. Suicide Res. 1–15 (2021).

  39. Nock, M. K. Why do people hurt themselves? New insights into the nature and functions of self-injury. Curr. Dir. Psychol. Sci. 18, 78–83 (2009).

    Article  PubMed  PubMed Central  Google Scholar 

  40. Peters, E. M. et al. Instability of suicidal ideation in patients hospitalized for depression: an exploratory study using smartphone ecological momentary assessment. Arch. Suicide Res. 26, 1–14 (2020).

    Google Scholar 

  41. Vansteelandt, K. et al. The affect stabilization function of nonsuicidal self-injury in borderline personality disorder: an ecological momentary assessment study. Behav. Res. Ther. 92, 41–50 (2017).

    Article  PubMed  Google Scholar 

  42. Houben, M. et al. The emotion regulation function of nonsuicidal self-injury: a momentary assessment study in inpatients with borderline personality disorder features. J. Abnorm. Psychol. 126, 89 (2017).

    Article  PubMed  Google Scholar 

  43. Santangelo, P. S. et al. Ecological momentary assessment of affective and interpersonal instability in adolescent non-suicidal self-injury. J. Abnorm. Child. Psych. 45, 1429–1438 (2017).

    Article  Google Scholar 

  44. Wolford-Clevenger, C. A daily diary study of intrusive PTSD symptoms and suicidal ideation among transgender and gender diverse adults. Psychol. Trauma-US 13, 768–771 (2017).

    Article  Google Scholar 

  45. Muehlenkamp, J. J. et al. Emotional states preceding and following acts of non-suicidal self-injury in bulimia nervosa patients. Behav. Res. Ther. 47, 83–87 (2009).

    Article  PubMed  Google Scholar 

  46. Hochard, K. D., Heym, N. & Townsend, E. The unidirectional relationship of nightmares on self-harmful thoughts and behaviors. Dreaming 25, 44–58 (2015).

    Article  Google Scholar 

  47. Czyz, E. K., King, C. A. & Nahum-Shani, I. Ecological assessment of daily suicidal thoughts and attempts among suicidal teens after psychiatric hospitalization: lessons about feasibility and acceptability. Psychiat. Res. 267, 566–574 (2018).

    Article  CAS  Google Scholar 

  48. Selby, E. A., Franklin, J., Carson-Wong, A. & Rizvi, S. L. Emotional cascades and self-injury: investigating instability of rumination and negative emotion. J. Clin. Psychol. 69, 1213–1227 (2013).

    Article  PubMed  Google Scholar 

  49. Selby, E. A. et al. The dynamics of pain during nonsuicidal self-injury. Clin. Psychol. Sci. 7, 302–320 (2019).

    Article  Google Scholar 

  50. Lear, M. K., Wilkowski, B. M. & Pepper, C. M. A daily diary investigation of the defective self-model among college students with recent self-injury. Behav. Ther. 50, 1002–1012 (2019).

    Article  PubMed  Google Scholar 

  51. Husky, M. et al. Predictors of daily life suicidal ideation in adults recently discharged after a serious suicide attempt: a pilot study. Psychiat. Res. 256, 79–84 (2017).

    Article  Google Scholar 

  52. Kaurin, A., Dombrovski, A.Y., Hallquit, M.N. & Wright, A.G. Momentary interpersonal processes of suicidal surges in borderline personality disorder. Psychol. Med. 1–11 (2020).

  53. Kaurin, A., Dombrovski, A., Hallquist, M. & Wright, A. G. Daily suicidal surge and attempted suicide in borderline personality disorder. Preprint at https://doi.org/10.31234/osf.io/hswea

  54. Forkmann, T. et al. Assessing suicidality in real time: a psychometric evaluation of self-report items for the assessment of suicidal ideation and its proximal risk factors using ecological momentary assessments. J. Abnorm. Psych. 127, 758–769 (2018).

    Article  Google Scholar 

  55. Kleiman, E. M. et al. Examination of real-time fluctuations in suicidal ideation and its risk factors: results from two ecological momentary assessment studies. J. Abnorm. Psych. 126, 726–738 (2017).

    Article  Google Scholar 

  56. Kleiman, E. M. et al. Examination of real-time fluctuations in suicidal ideation and its risk factors: results from two ecological momentary assessment studies. J. Abnorm. Psychol. 126, 726–738 (2017).

    Article  PubMed  Google Scholar 

  57. Salim, S., Robinson, M. & Flanders, C. E. Bisexual women’s experiences of microaggressions and micro affirmations and their relation to mental health. Psychol. Sex. Orientat. Gend. Divers. 6, 336 (2019).

    Article  Google Scholar 

  58. Hochard, K. D., Ashcroft, S., Carroll, J., Heym, N. & Townsend, E. Exploring thematic nightmare content and associated self‐harm risk. Suicide Life Threat. Behav. 49, 64–75 (2019).

    Article  PubMed  Google Scholar 

  59. Mou, D. et al. Negative affect is more strongly associated with suicidal thinking among suicidal patients with borderline personality disorder than those without. J. Psychiatr. Res. 104, 198–201 (2018).

    Article  PubMed  PubMed Central  Google Scholar 

  60. King, K. M., Feil, M. C. & Halvorson, M. A. Negative urgency is correlated with the use of reflexive and disengagement emotion regulation strategies. Clin. Psychol. Sci. 6, 822–834 (2018).

    Article  Google Scholar 

  61. Czyz, E. K. et al. Self‐efficacy to avoid suicidal action: factor structure and convergent validity among adults in substance use disorder treatment. Suicide Life Threat. Behav. 44, 698–709 (2014).

    Article  PubMed  PubMed Central  Google Scholar 

  62. Anestis, M. D., Pennings, S. M., Lavender, J. M., Tull, M. T. & Gratz, K. L. Low distress tolerance as an indirect risk factor for suicidal behavior: considering the explanatory role of non-suicidal self-injury. Compr. Psychiatry 54, 996–1002 (2013).

    Article  PubMed  Google Scholar 

  63. Versluis, A., Verkuil, B., Spinhoven, P., van der Ploeg, M. M. & Brosschot, J. F. Changing mental health and positive psychological well-being using ecological momentary interventions: a systematic review and meta-analysis. J. Med. Internet Res. 18, e152 (2016).

    Article  PubMed  PubMed Central  Google Scholar 

  64. Kirtley, O. J., Lafit, G., Achterhof, R., Hiekkaranta, A. P. & Myin-Germeys, I. Making the black box transparent: a template and tutorial for registration of studies using experience-sampling methods. Adv. Methods Pract. Psychol. Sci. 4, 2515245920924686 (2021).

    Google Scholar 

  65. Sliwinski, M. J. Measurement‐burst designs for social health research. Soc. Personal. Psychol. Compass 2, 245–261 (2008).

    Article  Google Scholar 

  66. King, C. A. et al. Five profiles of adolescents at elevated risk for suicide attempts: differences in mental health service use. J. Am. Acad. Child Adolesc. Psychiatry 59, 1058–1068 (2020).

    Article  PubMed  Google Scholar 

  67. Kaurin, A., Dombrovski, A. Y., Hallquist, M. N. & Wright, A. G. Integrating a functional view on suicide risk into idiographic statistical models. Behav. Res. Ther. 150, 104012 (2021).

    Article  PubMed  Google Scholar 

  68. Kuehn, K. S., Foster, K. T., Czyz, E. & King, C. A. Identifying person-specific coping responses to suicidal urges: a case series analysis and illustration of the idiographic method. Suicide Life Threat. Behav. https://doi.org/10.1111/sltb.12841 (2022).

  69. Wright, A. G. & Woods, W. C. Personalized models of psychopathology. Annu. Rev. Clin. Psychol. 16, 49–74 (2020).

    Article  PubMed  Google Scholar 

  70. Foster, K. T. & Beltz, A. M. Advancing statistical analysis of ambulatory assessment data in the study of addictive behavior: a primer on three person-oriented techniques. Addict. Behav. 83, 25–34 (2018).

    Article  PubMed  Google Scholar 

  71. Moher, D. et al. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med. 6, e1000097 (2009).

    Article  PubMed  PubMed Central  Google Scholar 

  72. Riley, R. D., Lambert, P. C. & Abo-Zaid, G. Meta-analysis of individual participant data: rationale, conduct, and reporting. Br. Med. J. 340, c221–c227 (2010).

    Article  Google Scholar 

  73. Enders, C. K. & Tofighi, D. Centering predictor variables in cross-sectional multilevel models: a new look at an old issue. Psychol. Methods 12, 121 (2007).

    Article  PubMed  Google Scholar 

  74. Gelman, A., Simpson, D. & Betancourt, M. The prior can often only be understood in the context of the likelihood. Entropy 19, 555–567 (2017).

    Article  Google Scholar 

  75. Bürkner, P. C. brms: an R package for Bayesian multilevel models using Stan. J. Stat. Softw. https://www.jstatsoft.org/v080/i01 (2017).

  76. R Core Team: R: a language and environment for statistical computing (R Foundation for Statistical Computing, 2013).

Download references

Acknowledgements

This research was supported by a National Research Service Award from the National Institute of Mental Health (F31MH117827, PI K.S.K.). The funders had no role in study design, data collection and analysis, decision to publish or preparation of the manuscript.

The authors thank the many individuals who contributed to this manuscript by sharing their data. We are grateful for their generosity and hope this work assists in our collective efforts to reduce the global burden of self-injury.

Author information

Authors and Affiliations

  1. Department of Psychology, University of Washington, Seattle, WA, USA

    Kevin S. Kuehn, Jonas Dora, Katherine T. Foster, Frank Song, Michele R. Smith & Kevin M. King

  2. Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA

    Melanie S. Harned

  3. Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA

    Melanie S. Harned

Authors
  1. Kevin S. Kuehn
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Jonas Dora
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Melanie S. Harned
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Katherine T. Foster
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Frank Song
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Michele R. Smith
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Kevin M. King
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

K.S.K: project planning and conceptualization, data curation, literature search, data analysis, software, writing (drafting and editing) and final approval. J.D.: data analysis, software, writing (drafting and editing) and final approval. M.S.H.: writing (drafting and editing) and final approval. K.A.F.: writing (drafting and editing) and final approval. F.S.: literature search, writing (drafting and editing) and final approval. M.R.S.: validation, writing (editing) and final approval. K.M.K.: project planning and conceptualization, data analysis, methodology, supervision, writing (drafting and editing) and final approval.

Corresponding author

Correspondence to Kevin S. Kuehn.

Ethics declarations

Competing interests

The authors declare no competing interests.

Peer review

Peer review information

Nature Human Behaviour thanks Glenn Kiekens, Raffaella Calati and the other, anonymous, reviewer(s) for their contribution to the peer review of this work. Peer reviewer reports are available.

Additional information

Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary information

Supplementary information

Supplementary Figs. 1–4 and Tables 1–9.

Reporting summary

Peer Review File

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Kuehn, K.S., Dora, J., Harned, M.S. et al. A meta-analysis on the affect regulation function of real-time self-injurious thoughts and behaviours. Nat Hum Behav 6, 964–974 (2022). https://doi.org/10.1038/s41562-022-01340-8

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1038/s41562-022-01340-8

This article is cited by

Search

Advanced search

Quick links

Nature Briefing

Sign up for the Nature Briefing newsletter — what matters in science, free to your inbox daily.

Get the most important science stories of the day, free in your inbox. Sign up for Nature Briefing