Journal of Abnormal Child Psychology

, Volume 45, Issue 5, pp 971–983 | Cite as

Examining the Course of Suicidal and Nonsuicidal Self-Injurious Thoughts and Behaviors in Outpatient and Inpatient Adolescents

  • Catherine R. Glenn
  • Elizabeth C. Lanzillo
  • Erika C. Esposito
  • Angela C. Santee
  • Matthew K. Nock
  • Randy P. Auerbach


Suicidal and nonsuicidal self-injurious thoughts and behaviors (SITBs) among youth are major public health concerns. Although a growing body of research has focused on the complex association between nonsuicidal and suicidal self-injury, the temporal relationship between these two classes of behaviors is unclear. The current study addresses this empirical gap by examining the course of SITBs in adolescents receiving outpatient (N = 106; 82.1 % female) and inpatient (N = 174; 75.9 % female) treatment. SITBs (co-occurrence, age-of-onset, and time lag between SITBs) and major psychiatric disorders were assessed at a single time point with well-validated structured interviews. Adolescents in both clinical samples reported high co-occurrence of SITBs: most adolescents reported both lifetime nonsuicidal self-injury (NSSI) and suicidal thoughts. A similar temporal pattern of SITBs was reported in the two samples: thoughts of NSSI and suicide ideation had the earliest age-of-onset, followed by NSSI behaviors, suicide plans, and suicide attempts. However, the age-of-onset for each SITB was younger in the inpatient sample than in the outpatient sample. In terms of time lag between SITBs, suicide ideation occurred on average before initial engagement in NSSI, suggesting that pathways to NSSI and suicidal behavior may occur simultaneously rather than in succession from nonsuicidal to suicidal self-injury. Results also indicated that the time to transition between SITBs was relatively fast, and that a key period for intervention and prevention is within the first 6–12 months after the onset of suicidal thinking. Taken together, these findings have important implications for understanding the time-lagged relationship between nonsuicidal and suicidal self-injury.


Self-injury Nonsuicidal self-injury Suicide Suicide attempts Adolescence 


Compliance with Ethical Standards


The research was partially supported by grants from the National Institute of Mental Health (F32MH097354 [CRG]; K23MH097786 [RPA]), the Rolfe Fund (RPA), the Tommy Fuss Fund (RPA), the Simches Fund (RPA), and with support from the John D. and Catherine T. MacArthur Foundation (MKN).

Conflict of Interest

The authors declare that they have no conflicts of interest.

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed Consent

Informed consent was obtained from all individual participants included in the study.


  1. American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: American Psychiatric Association.CrossRefGoogle Scholar
  2. Asarnow, J. R., Porta, G., Spirito, A., Emslie, G., Clarke, G., Wagner, K. D., et al. (2011). Suicide attempts and nonsuicidal self-injury in the treatment of resistant depression in adolescents: findings from the TORDIA study. Journal of the American Academy of Child and Adolescent Psychiatry, 50, 772–781.CrossRefPubMedPubMedCentralGoogle Scholar
  3. Auerbach, R. P., Millner, A. J., Stewart, J. G., & Esposito, E. C. (2015). Identifying differences between depressed adolescent suicide ideators and attempters. Journal of Affective Disorders, 186, 127–133.CrossRefPubMedPubMedCentralGoogle Scholar
  4. Avenevoli, S., Swendsen, J., He, J. P., Burstein, M., & Merikangas, K. R. (2015). Major depression in the National Comorbidity Survey–Adolescent Supplement: prevalence, correlates, and treatment. Journal of the American Academy of Child and Adolescent Psychiatry, 54, 37–44.CrossRefPubMedGoogle Scholar
  5. Barrocas, A. L., Hankin, B. L., Young, J. F., & Abela, J. R. (2012). Rates of nonsuicidal self-injury in youth: age, sex, and behavioral methods in a community sample. Pediatrics, 130, 39–45.CrossRefPubMedPubMedCentralGoogle Scholar
  6. Bryan, C. J., Bryan, A. O., May, A. M., & Klonsky, E. D. (2015). Trajectories of suicide ideation, nonsuicidal self-injury, and suicide attempts in a nonclinical sample of military personnel and veterans. Suicide and Life-threatening Behavior, 45, 315–325.CrossRefPubMedGoogle Scholar
  7. Carter, T. D. C., Mundo, E., Parikh, S. V., & Kennedy, J. L. (2003). Early age at onset as a risk factor for poor outcome of bipolar disorder. Journal of Psychiatric Research, 37, 297–303.CrossRefPubMedGoogle Scholar
  8. Centers for Disease Control and Prevention (CDC). (2010). Web-based Injury Statistics Query and Reporting System (WISQARS). National Center for Injury Prevention and Control, CDC. Available from URL Scholar
  9. Centers for Disease Control and Prevention (CDC). (2015). Injury Center: Violence prevention—suicide prevention: Youth suicide. Retrieved from
  10. Giletta, M., Prinstein, M. J., Abela, J. R., Gibb, B. E., Barrocas, A. L., & Hankin, B. L. (2015). Trajectories of suicide ideation and nonsuicidal self-injury among adolescents in mainland China: peer predictors, joint development, and risk for suicide attempts. Journal of Consulting and Clinical Psychology, 83, 265–279.CrossRefPubMedGoogle Scholar
  11. Glenn, C. R., & Klonsky, E. D. (2013). Nonsuicidal self-injury disorder: an empirical investigation in adolescent psychiatric patients. Journal of Clinical Child & Adolescent Psychology, 42, 496–507.CrossRefGoogle Scholar
  12. Grandclerc, S., De Labrouhe, D., Spodenkiewicz, M., Lachal, J., & Moro, M. R. (2016). Relations between nonsuicidal self-injury and suicidal behavior in adolescence: a systematic review. PloS One, 11, e0153760.CrossRefPubMedPubMedCentralGoogle Scholar
  13. Guan, K., Fox, K. R., & Prinstein, M. J. (2012). Nonsuicidal self-injury as a time-invariant predictor of adolescent suicide ideation and attempts in a diverse community sample. Journal of Consulting and Clinical Psychology, 80, 842–849.CrossRefPubMedPubMedCentralGoogle Scholar
  14. Hamza, C. A., Stewart, S. L., & Willoughby, T. (2012). Examining the link between nonsuicidal self-injury and suicidal behavior: a review of the literature and an integrated model. Clinical Psychology Review, 32, 482–495.CrossRefPubMedGoogle Scholar
  15. Jacobson, C. M., & Gould, M. (2007). The epidemiology and phenomenology of non-suicidal self-injurious behavior among adolescents: a critical review of the literature. Archives of Suicide Research, 11, 129–147.CrossRefPubMedGoogle Scholar
  16. Kar, N., & Bastia, B. K. (2006). Post-traumatic stress disorder, depression and generalized anxiety disorder in adolescents after a natural disaster: a study of comorbidity. Clinical Practice and Epidemiology in Mental Health, 2, 17–23.CrossRefPubMedPubMedCentralGoogle Scholar
  17. Kessler, R. C., Borges, G., & Walters, E. E. (1999). Prevalence of and risk factors for lifetime suicide attempts in the National Comorbidity Survey. Archives of General Psychiatry, 56, 617–626.CrossRefPubMedGoogle Scholar
  18. Klonsky, E. D., May, A. M., & Glenn, C. R. (2013). The relationship between nonsuicidal self-injury and attempted suicide: converging evidence from four samples. Journal of Abnormal Psychology, 122, 231–237.CrossRefPubMedGoogle Scholar
  19. Maciejewski, D. F., Creemers, H. E., Lynskey, M. T., Madden, P. A., Heath, A. C., Statham, D. J., et al. (2014). Overlapping genetic and environmental influences on nonsuicidal self-injury and suicidal ideation: different outcomes, same etiology? JAMA Psychiatry, 71, 699–705.CrossRefPubMedPubMedCentralGoogle Scholar
  20. Merikangas, K. R., He, J. P., Burstein, M., Swanson, S. A., Avenevoli, S., Cui, L., et al. (2010). Lifetime prevalence of mental disorders in US adolescents: results from the National Comorbidity Survey Replication–Adolescent Supplement (NCS-A). Journal of the American Academy of Child and Adolescent Psychiatry, 49, 980–989.CrossRefPubMedPubMedCentralGoogle Scholar
  21. Millner, A. J., Lee, M. D., & Nock, M. K. (2015). Single-item measurement of suicidal behaviors: validity and consequences of misclassification. PloS One, 10, e0141606.CrossRefPubMedPubMedCentralGoogle Scholar
  22. Moor, S., Crowe, M., Luty, S., Carter, J., & Joyce, P. R. (2012). Effects of comorbidity and early age of onset in young people with bipolar disorder on self-harming behaviour and suicide attempts. Journal of Affective Disorders, 136, 1212–1215.CrossRefPubMedGoogle Scholar
  23. Muehlenkamp, J. J., & Gutierrez, P. M. (2004). An investigation of differences between self- injurious behavior and suicide attempts in a sample of adolescents. Suicide and Life-threatening Behavior, 34, 12–23.CrossRefPubMedGoogle Scholar
  24. Muehlenkamp, J. J., Ertelt, T. W., Miller, A. L., & Claes, L. (2011). Borderline personality symptoms differentiate non-suicidal and suicidal self-injury in ethnically diverse adolescent outpatients. Journal of Child Psychology and Psychiatry, 52, 148–155.CrossRefPubMedGoogle Scholar
  25. Muehlenkamp, J. J., Claes, L., Havertape, L., & Plener, P. L. (2012). International prevalence of adolescent non-suicidal self-injury and deliberate self-harm. Child and Adolescent Psychiatry and Mental Health, 6, 1–9.CrossRefGoogle Scholar
  26. Nock, M. K. (2010). Self-injury. Annual Review of Clinical Psychology, 6, 339–363.CrossRefPubMedGoogle Scholar
  27. Nock, M. K., & Kessler, R. C. (2006). Prevalence of and risk factors for suicide attempts versus suicide gestures: analysis of the National Comorbidity Survey. Journal of Abnormal Psychology, 115, 616–623.CrossRefPubMedGoogle Scholar
  28. Nock, M. K., Joiner, T. E., Gordon, K. H., Lloyd-Richardson, E., & Prinstein, M. J. (2006). Nonsuicidal self-injury among adolescents: diagnostic correlates and relation to suicide attempts. Psychiatry Research, 144, 65–72.CrossRefPubMedGoogle Scholar
  29. Nock, M. K., Holmberg, E. B., Photos, V. I., & Michel, B. D. (2007). Self-injurious thoughts and behaviors interview: development, reliability, and validity in an adolescent sample. Psychological Assessment, 19, 309–317.CrossRefPubMedGoogle Scholar
  30. Nock, M. K., Borges, G., Bromet, E. J., Alonso, J., Angermeyer, M., Beautrais, A., Bruffaerts, R., et al. (2008a). Cross-national prevalence and risk factors for suicidal ideation, plans, and attempts. British Journal of Psychiatry, 192, 98–105.CrossRefPubMedPubMedCentralGoogle Scholar
  31. Nock, M. K., Borges, G., Bromet, E. J., Cha, C. B., Kessler, R. C., & Lee, S. (2008b). Suicide and suicidal behavior. Epidemiologic Reviews, 30, 133–154.CrossRefPubMedPubMedCentralGoogle Scholar
  32. Nock, M. K., Prinstein, M. J., & Sterba, S. K. (2009). Revealing the form and function of self-injurious thoughts and behaviors: a real-time ecological assessment study among adolescents and young adults. Journal of Abnormal Psychology, 118, 816–827.CrossRefPubMedPubMedCentralGoogle Scholar
  33. Nock, M. K., Borges, G., & Ono, Y. (2012). Suicide: global perspectives from the WHO world mental health surveys. New York, NY: Cambridge University Press.Google Scholar
  34. Nock, M. K., Green, J. G., Hwang, I., McLaughlin, K. A., Sampson, N. A., Zaslavsky, A. M., & Kessler, R. C. (2013). Prevalence, correlates, and treatment of lifetime suicidal behavior among adolescents: results from the National Comorbidity Survey Replication Adolescent Supplement. JAMA Psychiatry, 70, 300–310.CrossRefPubMedGoogle Scholar
  35. Oliver, M. I., Pearson, N., Coe, N., & Gunnell, D. (2005). Help-seeking behaviour in men and women with common mental health problems: cross-sectional study. The British Journal of Psychiatry, 186, 297–301.CrossRefPubMedGoogle Scholar
  36. Rueter, M. A., Holm, K. E., McGeorge, C. R., & Conger, R. D. (2008). Adolescent suicidal ideation subgroups and their association with suicidal plans and attempts in young adulthood. Suicide and Life-threatening Behavior, 38, 564–575.CrossRefPubMedGoogle Scholar
  37. Scott, L. N., Pilkonis, P. A., Hipwell, A. E., Keenan, K., & Stepp, S. D. (2015). Non-suicidal self-injury and suicidal ideation as predictors of suicide attempts in adolescent girls: a multi-wave prospective study. Comprehensive Psychiatry, 58, 1–10.CrossRefPubMedGoogle Scholar
  38. Sheehan, D., Shytle, D., Milo, K., Janavs, J., & Lecrubier, Y. (2009). Mini international neuropsychiatric interview for children and adolescents (M.I.N.I. Kid), English version 6.0. Tampa, FL: University of South Florida College of Medicine.Google Scholar
  39. Sheehan, D. V., Sheehan, K. H., Shytle, R. D., Janavs, J., Bannon, Y., Rogers, J. E., et al. (2010). Reliability and validity of the mini international neuropsychiatric interview for children and adolescents (MINI-KID). Journal of Clinical Psychiatry, 71, 313–326.CrossRefPubMedGoogle Scholar
  40. Stewart, J. G., Kim, J. C., Esposito, E. C., Gold, J., Nock, M. K., & Auerbach, R. P. (2015). Predicting suicide attempts in depressed adolescents: clarifying the role of disinhibition and child sexual abuse. Journal of Affective Disorders, 187, 27–34.CrossRefPubMedPubMedCentralGoogle Scholar
  41. Tuisku, V., Kiviruusu, O., Pelkonen, M., Karlsson, L., Strandholm, T., & Marttunen, M. (2014). Depressed adolescents as young adults–predictors of suicide attempt and non-suicidal self-injury during an 8-year follow-up. Journal of Affective Disorders, 152, 313–319.CrossRefPubMedGoogle Scholar
  42. van Alphen, N. R., Stewart, J. G., Esposito, E. C., Pridgen, B., Gold, J., & Auerbach, R. P. (in press). Predictors of rehospitalization for depressed adolescents admitted to acute psychiatric treatment. The Journal of Clinical Psychiatry. Google Scholar
  43. Victor, S. E., & Klonsky, E. D. (2014). Correlates of suicide attempts among self-injurers: a meta-analysis. Clinical Psychology Review, 34, 282–297.CrossRefPubMedGoogle Scholar
  44. Whitlock, J., Muehlenkamp, J., Purington, A., Eckenrode, J., Barreira, P., Baral Abrams, G., et al. (2011). Nonsuicidal self-injury in a college population: general trends and sex differences. Journal of American College Health, 59, 691–698.CrossRefPubMedGoogle Scholar
  45. Wilkinson, B. J., Marshall, R. M., & Curtwright, B. (2008). Impact of Tourette’s disorder on parent reported stress. Journal of Child and Family Studies, 17, 582–598.CrossRefGoogle Scholar
  46. Wilkinson, P., Kelvin, R., Roberts, C., Dubicka, B., & Goodyer, I. (2011). Clinical and psychosocial predictors of suicide attempts and nonsuicidal self-injury in the adolescent depression antidepressants and psychotherapy trial (ADAPT). American Journal of Psychiatry, 168, 495–501.CrossRefPubMedGoogle Scholar
  47. Zetterqvist, M., Lundh, L. G., Dahlström, Ö., & Svedin, C. G. (2013). Prevalence and function of non-suicidal self-injury (NSSI) in a community sample of adolescents, using suggested DSM-5 criteria for a potential NSSI disorder. Journal of Abnormal Child Psychology, 41, 759–773.CrossRefPubMedGoogle Scholar
  48. Zisook, S., Lesser, I., Stewart, J. W., Wisniewski, S. R., Balasubramani, G. K., Fava, M., et al. (2007). Effect of age at onset on the course of major depressive disorder. American Journal of Psychiatry, 164, 1539–1546.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2016

Authors and Affiliations

  • Catherine R. Glenn
    • 1
  • Elizabeth C. Lanzillo
    • 2
  • Erika C. Esposito
    • 3
  • Angela C. Santee
    • 1
  • Matthew K. Nock
    • 4
  • Randy P. Auerbach
    • 3
  1. 1.Clinical and Social Sciences in PsychologyUniversity of RochesterRochesterUSA
  2. 2.Department of PsychologyBrown UniversityProvidenceUSA
  3. 3.Department of Psychiatry, Harvard Medical School; Center for Depression, Anxiety and Stress ResearchMcLean HospitalBelmontUSA
  4. 4.Department of PsychologyHarvard UniversityCambridgeUSA

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