Page 104 - Personality disorders and insecure attachment among adolescents

Introduction
Non-suicidal self-injury (NSSI; e.g., self-inflicted burning, cutting, and punching) among youth is a major public health concern (Glenn et al., 2016). Apparently, it is common but often hidden behaviour, especially among adolescents with psychiatric problems (Lockwood, Townsend, Royes, Daley, & Sayal, 2018; Madge et al., 2011). Furthermore, it is associated with elevated psychopathology, risk of suicide attempts, and demand for clinical services (Ougrin, Tranah, Leigh, Taylor, & Rosenbaum Asarnow, 2012; Rodav, Levy, & Hamdan, 2014). Knowledge of NSSI in a high-risk adolescent sample can help us better understand this behaviour and optimize prevention and treatment.
Non-suicidal self-injury prevalence is 17.2% among adolescents and 13.4% among young adults (Swannell, Martin, Page, Hasking, & St John, 2014). The age of onset of NSSI is generally between 12 and 16, and the onset is younger in inpatient adolescents than in outpatient adolescents (Glenn et al., 2016; Kiekens et al., 2015). Non-suicidal self-injury is common among adolescents in clinical practice and it is associated with significant functional impairment (Madge et al., 2011). The prevalence rates of NSSI among inpatient adolescents varies from approximately 35% to 80%, depending on numerous methodological variations and different definitions (Hawton, Saunders, & O'Connor, 2012; Koenig et al., 2017; Madge et al., 2011; Zetterqvist, 2015). Half of the heterogeneity in these prevalence estimates, can be explained by methodological factors such as measurement errors and differences in assessment and sampling strategies (Swannell et al., 2014).
Also, actual differences in NSSI prevalence between countries may be caused by cultural differences with respect to socio-cultural norms, traditions, as well as substance use policies (Brunner et al., 2013; Ougrin et al., 2012). Cultural differences, likely influence risk factors such as substance use, family integrity and neglect, childhood family adversity, peer rejection, victimization, and socioeconomic status (Brunner et al., 2013; Cassels et al., 2018; Giletta, Scholte, Engels, Ciairano, & Mitchell, 2013; Ougrin et al., 2012). Apart from cultural differences, NSSI may also vary as a function of gender, ethnic background, and school-level (Gratz et al., 2012; Hawton et al., 2012). Furthermore, emotional instability in adolescence could partly explain the variability in prevalence rates of NSSI (Kaltiala-Heino & Eronen, 2015).
The distinction between non-suicidal and suicidal self-injury has been a topic of discussion for the last twenty years (Grandclerc, De Labrouhe, Spodenkiewicz, Lachal, & Moro, 2016; Lloyd- Richardson, Nock, & Prinstein, 2009; Zanarini, Laudate, Frankenburg, Wedig, & Fitzmaurice, 2013) due to the fact that most people engaging in NSSI also report suicidal ideation (Glenn et al., 2016; Klonsky, May, & Glenn, 2013; Whitlock et al., 2013). Although most studies consider NSSI an integral feature of borderline personality disorder (BPD), a rapidly growing body of empirical research demonstrates that NSSI co-occurs with a variety of psychiatric disorders, including depression, substance abuse disorders, post-traumatic stress disorder, eating disorders, and other personality disorders (Cawood & Huprich, 2011; Gratz, Dixon-Gordon, Chapman, & Tull, 2015; Wilkinson,
98