AD ALTA
JOURNAL OF INTERDISCIPLINARY RESEARCH
hand, it is necessary to analyse the impact that the narrowing of
the diagnostic criteria might have on the identification of real
cases of self-harm. If the narrowing of the criteria was practical
but led to the drop-out of an overly large number of cases, it
would be inappropriate.
Thus, in order to evaluate the advantages and disadvantages of
the individual systems, it is desirable to analyse the drop-out,
which is an indicator of the number of individuals that do not fall
into the criteria set out in the three diagnostic approaches. A
simple observation of the prevalence of individual forms of self-
harm is not satisfactory in this case. Even though this may
identify that, for example, indirect or mental forms of self-harm
are just as frequent as direct physical forms, and thus provide
valuable data for the correct understanding of the concept, it
does not mean that all forms must fulfil the diagnostic criteria. In
fact, it is quite possible that certain forms of self-harm (such as
the above mentioned indirect or mental forms) are common, but
are only rarely present without direct physical forms. And should
this be true, the NSSI definition from DSM-5 would be limiting,
but quite satisfactory to identify cases for diagnostic purposes.
2 Objective
The objective of the paper is:
to employ three independent systems for the detection of
self-harm (DSM-5 criteria, ICD-10 criteria, SHI-criteria);
to discover what percentage of the observed cases of self-
harm in the study population of adolescents can be
captured by these systems;
to evaluate the differences in the sensitivity of the
individual systems and to assess their effectiveness in the
diagnosis of self-harm.
3 Method
3.1 Participants and Procedure
The study sample was comprised of 2,210 Slovak adolescents
(63.3% of whom were female) between the ages of 11 and 19
(mean age = 15.3; st. dev. = 1.67 years) who were in primary
and secondary education. All participants were enrolled in the
public-school system and were recruited from classes that were
randomly selected from various public schools that represent all
the different types of schools. Of the initial number of 2,210
responses, 387 (17.5%) were excluded due to a lack of complete
data. Thus 1,823 adolescents were included in the statistical
analyses. The data was collected anonymously from the subjects
who (or their guardians) had given their informed consent for
their participation. The questionnaire was administered in a
standard manner by trained administrators.
3.2 Measures and Statistical Analysis
The platform used for the collection of data was a modified SHI
questionnaire (The Self-Harm Inventory – Sansone & Sansone
2010). The original SHI is a self-assessment questionnaire that
includes 22 questions that assess the existence of individual
forms of self-harming behaviour. The items are preceded by the
phrase “Have you ever intentionally, deliberately to cause
yourself harm…” followed by the different forms of self-harm:
“cut yourself, burned yourself, hit yourself, scratched yourself”,
etc. (for all the items see Table 1). The items were slightly
modified according to studies that observed the prevalence of the
most frequent forms of self-harm in the study population (see
e.g. Demuth & Demuthova 2019; Demuthova & Demuth 2019B)
and the participants were also asked to report how many times
they had repeated the behaviour as well as the frequency
(0=never, 1=rarely, 2=sometimes, 3=often). The relatively high
internal consistency of this method has been confirmed through
an analysis (C
ronbach’s α=0.809) (see e.g. Demuthova &
Doktorova 2019). The aim of the questionnaire was to detect the
presence and extent of the most common forms of self-harm. It
also separated self-harming individuals from the studied group –
in order to classify a participant as a member of the group of
self-harming individuals, it was necessary that they admitted to
at least one form of self-harming behaviour with a frequency of
2 or 3 (sometimes or often), or to several forms of self-harming
behaviour with a frequency of 1 or above.
The DSM-5 system only considers direct physical forms of self-
harm and excludes attempted suicide. Hence, according to this
criteria, self-harming individuals are those who reported at least
one of the direct forms of self-harming behaviour in the SHI
questionnaire (for the list, see Table 1). The ICD-10 system,
with its broader categorisation, increases the number of observed
types of self-harm with items that fall under the indirect forms of
self-harm; however, it still does not take mental self-harm into
account. All the indirect physical forms of self-harm were
included in this system as they meet the criteria of the X84
category (“Intentional self-harm by unspecified means”). The
SHI questionnaire represents the broadest diagnostic system,
mapping a wide range of forms of self-harm. Within this system,
self-harmers are identified as those individuals who meet one
basic criterion – an admission to at least one form of self-
harming behaviour with a frequency of 2 or 3 (sometimes or
often), or an admission to several forms of self-harming
behaviour with a frequency of 1 or above.
Tab. 1: Observed forms of self-harm and their classification in
the individual systems
Have you ever intentionally, or
on purpose, done any of the
following:
Diagnostic systems
Forms of self-harm:
DSM-5 ICD-10
SHI
Direct physical self-harm:
Scratched yourself on purpose
x
x
x
Hit yourself
x
x
x
Cut yourself on purpose
x
x
x
Exercised an injury on purpose
x
x
x
Banged your head on purpose
x
x
x
Prevented wounds from healing
x
x
x
Burned yourself on purpose
x
x
x
Attempted suicide*
x
x
Indirect physical self-harm:
Abused alcohol to hurt yourself
x
x
Not slept enough to hurt yourself
x
x
Starved yourself to hurt yourself
x
x
Over-exercised to hurt yourself
x
x
Made medical situations worse
on purpose
x
x
Overdosed
x
x
Abused prescription medication
x
x
Abused laxatives to hurt yourself
x
x
Mental self-harm:
Distanced yourself from God as
a punishment
x
Set yourself up in a relationship
to be rejected
x
Tortured yourself with self-
defeating thoughts
x
Engaged in emotionally abusive
relationships
x
*Note: Although attempted suicide is a direct and physical form
of self-harm, DSM-5 strictly excludes it. For this reason, it was
included in the ICD-10 and SHI systems.
Source: authors
The data analysis was conducted using IBM SPSS 22 statistical
software. The statistical significance threshold (α) in each data
analysis was set to 0.05.
4 Results
The first diagnostic criteria, based on the mapping of self-harm
from the modified SHI questionnaire, detected 830 cases. The
narrower diagnostic system, based on the ICD criteria, detected
803 cases, and the narrowest system, based on DSM-5, only 701
cases (see Table 2).
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