AD ALTA
JOURNAL OF INTERDISCIPLINARY RESEARCH
THE ANALYSIS OF DROP-OUT IN THE POTENTIAL DIAGNOSTIC SYSTEMS FOR SELF-HARM
IN THE ADOLESCENT POPULATION
a
SLAVKA DEMUTHOVA,
b
OGNEN SPASOVSKI
University of Ss. Cyril and Methodius in Trnava, Nam. J. herdu
2, 917 01 Trnava, Slovakia
email:
a
slavka.demuthova@ucm.sk,
b
ognen.spasovski@ucm.sk
This work was supported by the Slovak Research and Development Agency under
contract No. APVV-17-0123.
Abstract: The paper addresses the potential for the identification of self-harming
individuals in the adolescent population through three different systems – the SHI
questionnaire (Self-Harm Inventory), the definitions of intentional self-harm from
ICD-10 and the diagnostic criteria listed for Non-Suicidal Self-Injury in DSM-5. It is
followed by an evaluation of their effectiveness based on the extent of the undetected
cases of self-harm. The study was conducted on a sample of 2,210 Slovak adolescents
aged from 11 to 19 (mean age = 15.3; st. dev. = 1.67 years). The DSM-5 system
proved to be the least effective, with a statistically significant (sig. = 0.000) drop-out
of cases. For the purpose of diagnosing self-harm in the adolescent population, we
propose a checklist of the forms of self-harm, which would, in addition to direct forms
of physical self-harm, also include indirect physical and mental forms.
Keywords: self-harm, diagnostics, prevalence, adolescents.
1 Introduction
One of the problems in the implementation of new nosological
classifications is the determination of the diagnostic criteria. It is
a relatively complicated process, which must work when applied
to the symptoms of the specific disorder and surrounding
circumstances as accurately as possible. For instance, it must
define a disorder in a way that is distinct from other disorders,
whether related or comorbid, and exhaustively set out a unique
combination of symptoms, its typical longevity (possibly non-
interchangeable), often along with a set of symptoms which
cannot be present in the disorder (Balogh, Miller, & Ball 2015).
In clinical psychology and psychiatry, the process is even more
complicated as many of the symptoms of mental disorders and
difficulties are related to the subjective experience of the
individual affected and since there are only a few biological tests
that are available for use in the diagnosis (Pincus 2014), it is
only rarely possible to measure them in an exact manner, as is
done in the field of medicine. Yet, there are diagnostic manuals
available in psychology and psychiatry that point to the presence
of a mental disorder using the registration of symptoms – these
mainly include international systems of classification such as the
DSM (Diagnostic and Statistical Manual of Mental Disorders)
and ICD (International Classification of Diseases).
Experts who have observed the mental health of young children
and adolescents over the last few decades have reported an
increase in the number of mental problems and difficulties. This
includes both the prevalence of problems (see e.g. Comeau,
Georgiades, Duncan, Wang, Boyle, & 2014 Ontario Child
Health Study Team 2019; Chadda 2018; Jurewicz 2015), as well
as the emergence of new forms of mental difficulties that are still
not reflected in the diagnostic manuals. One of these forms is
self-harm – a maladaptive strategy for coping with mental
problems in youth, leading to intentional harm of one’s own
health. Self-harm as such is not a novel concept in psychology
and psychiatry. However, in the past it was associated with
certain psychiatric diagnoses and mental disorders – autism
(Maddox 2017), mental retardation (van den Bogaard, Nijman,
Palmstierna, & Embregts 2018), attempted suicide (Brent 2011),
borderline personality disorder (Glenn & Klonsky 2013), sexual
abuse (Klonsky, Victor, & Saffer 2014),… and was considered
to be a concomitant symptom of these diagnoses. Yet, recent
research has suggested that self-harm tends to appear in the
psychiatrically intact adolescent population and that it occurs
independently of any diagnosis of borderline personality
disorder (Glenn & Klonsky 2013) or sexual abuse (Klonsky &
Moyer 2008).
This data has clearly proved that self-harm as a diagnosis should
be removed from the field of psychiatric conditions and
transferred into the field of clinical psychology or the area of
work with the non-clinical adolescent population. This is also
confirmed by international studies that sometimes report the
prevalence of self-harm among youths at a level of 20 – 70%
(Swahn, Ali, Bossarte, Van Dulmen, Crosby, Jones, & Schinka
2012; Plener, Libal, Keller, Fegert, & Muehlenkamp 2009; Dyl
2008; Hallab & Covic 2010), with a proportion of them being
included in the non-clinical population (Burešová 2012). In the
Slovak population (Démuthová & Démuth 2020), this
phenomenon appears to affect approximately 45% of
adolescents. A possible reason that the data on the prevalence of
self-harm exhibits such a very wide spectrum of values in the
various studies (from 1% – Madge et al. 2008; up to 69% –
Hallab & Covic 2010) is the lack of a clear definition and
diagnostic criteria for self-harming behaviour. Certain diagnostic
systems consider self-harm to only be behaviour that exclusively
leads to visible physical damage to the bodily tissue (cutting,
burning, etc. used in studies e.g. by Rojkova & Mickova 2020),
while other systems also include less visible forms (e.g. the
intentional consumption of indigestible objects, taking drugs not
prescribed by a doctor or intentionally failing to follow a
prescribed treatment) or even mental self-harm (e.g. torturing
with self-defeating thoughts, setting up in a relationship to be
rejected).
Hence, there are several definitions and possible “diagnostic
systems” for the evaluation of self-harm – generally, they may
be classified into three groups. The first is the narrowest and is
represented by the most recent (fifth) revision of the Diagnostic
and Statistical Manual of Mental Disorders (DSM-5), published
by the APA (American Psychiatric Association). It has proposed
diagnostic criteria for “Non-Suicidal Self-Injury” (NSSI)
disorder in “Section III – Emerging Measures and Models” and
it defines NSSI as: “intentional self-inflicted damage to the
surface of their body of a sort likely to induce bleeding, bruising,
or pain (e.g. cutting, burning, stabbing, hitting, excessive
rubbing), with the expectation that the injury will only lead to
minor or moderate physical harm (i.e. there is no suicidal
intent)” (DSM-5 2013, 803). The second may be implicitly
identified in the diagnostic system ICD-10 (International
Statistical Classification of Diseases and Related Health
Problems, 10th version). It defines the term “intentional self-
harm” as a wide range of behaviours (see categories X60 – X84)
and it is a category that falls under “External Causes of
Morbidity and Mortality” (ICD-10, 2016). The extent of the
individual types of self-harming behaviour in ICD-10 is broader
than in DSM-5 and includes hidden/indirect physical self-harm,
such as deliberate poisoning, taking drugs not prescribed by a
doctor and the like. Finally, there are approaches that view self-
harm as any intentional act that results in damage to health of the
individual – whether physical or mental. One such approach is
the creation of a methodology to measure self-harm – the SHI
questionnaire (Self-Harm Inventory – Sansone & Sansone 2010),
which is intended to capture various types and forms of this
behaviour.
It is clear that the definition of what should (or should not) be
deemed self-harm and which diagnostic criteria should be used
will have a significant impact on the data obtained with regard to
prevalence. Consequently, an individual may be captured under
one system and not by another, and as a result, they may not be
diagnosed and provided with the necessary intervention and
treatment. Previous observations of this issue have revealed, for
instance, that of the 835 participants identified as self-harming
by the SHI, 41.9% (N=350) exhibit self-harming behaviour
which, according to the DSM-5 criteria, is not classified as
belonging to NSSI ((Demuthova & Demuth 2019
A
). At the same
time, it is appropriate to limit the number of observed symptoms
to the minimum necessary in order to ensure the efficiency of the
diagnostic tools. The principle of Occam’s razor in science
postulates that the optimal strategy is to work with the smallest
number of elements possible in any given situation. On the other
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