Child Psychiatry Hum Dev (2008) 39:427438

DOI 10.1007/s10578-008-0100-2

ORIGINAL ARTICLE

Psychiatric Correlates of Nonsuicidal Cutting Behaviors

in an Adolescent Inpatient Sample

Lance P. Swenson Anthony Spirito Jennifer Dyl Jennifer Kittler

Jeffrey I. Hunt

Published online: 22 March 2008

Springer Science+Business Media, LLC 2008

Abstract This archival study of 288 adolescent psychiatric inpatients examined the
psychiatric correlates of cutting behavior. Participants were categorized into Threshold
cutters (n = 61), Subthreshold cutters (n = 43), and Noncutters (n = 184). Groups were
compared on psychiatric diagnoses, suicidality, and self-reported impairment. Results
demonstrated that females were more likely to cut relative to males; however, gender did
not affect the correlates of cutting behavior. Adolescents in the Threshold group were more
likely to be diagnosed with Major Depression and had higher self-reported suicidality,
depression, and trauma-related symptoms of depression and dissociation relative to the
Noncutting group. The Subthreshold group did not differ from the other groupings except
for an elevated risk for Posttraumatic Stress Disorder compared to the Noncutting group.

Keywords Self-cutting
Adolescents
Gender
Psychiatric correlates

Nonsuicidal self-injurious behavior (NSSI), also known as self-mutilation [1], refers to

purposeful damaging of body tissue without the intent to die [2, 3]. Adolescence is a period
of particular risk for NSSI [47]. Studies of NSSI in community-based adolescent samples
reveal prevalence rates of 114% [8, 9], compared to rates of 4% among adults [10].
Among treatment-seeking adolescents, prevalence rates of 3861% have been reported [11,
12]. Of particular concern, findings from both community and clinical populations

L. P. Swenson
A. Spirito
Center for Alcohol and Addiction Studies, The Warren Alpert Medical School at Brown University,
Box G-121-4, Providence, RI 02912, USA
e-mail: Lance_Swenson@Brown.edu

J. Dyl
J. Kittler
J. I. Hunt

The Warren Alpert Medical School at Brown University and the Bradley Hospital,
Providence, RI, USA

J. I. Hunt (&)
Bradley Hospital, 1011 Veterans Memorial Parkway, East Providence, RI 02915, USA
e-mail: JHunt@Lifespan.org

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document relations between adolescent NSSI and depression and anxiety [9, 1115],
oppositional/conduct problems [11, 1417], substance abuse [14, 18], suicidality [12, 13,
19], and a history of abuse [20, 21].
Cutting (i.e., nonlifethreatening carving on the skin) is widely recognized as the most
common form of adolescent NSSI, occurring in 1465% of community-based adolescent
NSSI samples [8, 13, 15, 17] and between 4298% of clinical NSSI populations [12, 22, 23].
Relatively little research has investigated the psychological correlates specific to cutting even
though cutting has been proposed to serve different functions, and may be associated with
different correlates, compared to other forms of NSSI (e.g., head-banging) [24]. Kumar and
colleagues [25], in one of the few studies focused on adolescent cutting, found that both the
number and intensity of reasons for cutting were related to depression. Similarly, Rodham and
colleagues [8] found that female cutters were more likely than male cutters to endorse self-
punishment and obtaining relief from distress to explain their cutting behavior. In addition,
Fortune [22] found that adolescent outpatients with a history of cutting were more likely to
report previous suicidal ideation relative to those who engaged in other forms of NSSI.
Although NSSI more generally and cutting specifically is described as a repetitive act [2,
24], variability in the frequency and intensity of NSSI exists. However, researchers often
ignore this fact. Instead, adolescents with differing histories of NSSI engagement are typically
examined as a single group [e.g., 12] or are selected based upon the frequency with which they
engage in NSSI [e.g., 25]. Nock and colleagues [14] found that the number of NSSI methods
used and the number of years engaging in NSSI were related to number of lifetime suicide
attempts (rs = .23 and .30, respectively). The number of distinct NSSI episodes, on the other
hand, was not related to lifetime suicide attempts. Importantly this study did not examine
repeated cutting specifically and instead focused on NSSI more generally [14].
The present, archival study of an adolescent psychiatric inpatient sample examines
psychiatric impairment related to differing levels of engagement in cutting behavior. We
hypothesized that adolescents with a history of cutting would endorse elevated symptoms
of impairment across domains and would evidence greater psychiatric comorbidity com-
pared to adolescent inpatients with no cutting history. In addition, we expected repetitive/
severe cutters to evidence elevated psychopathology, in terms of diagnosis and self-
reported impairment, compared to infrequent/minor cutters.

Method

Participants

Participants included 288 adolescent inpatients (64% female) at a psychiatric hospital

located in the Northeast. They were selected from 401 consecutive admissions between
March 2004July 2005. Patients were excluded if they did not complete either the diag-
nostic interview or the intake battery (i.e., due to unexpected discharge or refusal to
cooperate; n = 56), due to active psychosis or significant cognitive impairment (n = 34),
or if there was insufficient information to determine whether the participant engaged in
cutting (n = 5). Also, patients who reported only minor/infrequent cutting occurring more
than 2 years prior to their admission were excluded (n = 18). Participants were 11 to
18 years old (M = 14.91; SD = 1.47). Self-identified racial/ethnic background was 72%
Caucasian, 10% Hispanic/Latino, 6% African American, 2% Asian American, and 6%
other (e.g., mixed ethnicity). The hospital from which the participants were drawn
mainly serves patients of lower and middle socioeconomic status.

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Procedures

The diagnostic interview and the self-report rating scales described below were adminis-
tered by trained mental health workers as part of the standard intake battery. Participants
were assessed within 1 week of admission, typically within the first three days.
Demographic information, current and lifetime cutting behavior, and current and life-
time suicidality were collected via chart reviews. Cutting history and history of suicidality
were documented in several reports (i.e., intake, psychosocial history, psychiatric inter-
view). The hospital Human Subjects Review Committee permitted the use of this archival
data.

Measures

Cutting Group Classification

Chart reviews assessed current and lifetime cutting behaviors using the non-suicidal
physical self-damaging acts module of the Schedule for Affective Disorders and Schizo-
phrenia for School Aged Children (K-SADS-PL) [26]. Consistent with the K-SADS-PL
scoring criteria, adolescents who had cut themselves four or more times or had caused
injury requiring medical intervention and who had engaged in at least one episode of
cutting in the past 2 years were categorized as Threshold cutters (n = 61; 21%). Ado-
lescents with 13 cutting episodes, at least one of which occurred within the past 2 years,
and whose cutting had not caused serious injury were categorized as Subthreshold cutters
(n = 43; 15%). Adolescents with no history of cutting were categorized as Noncutters
(n = 184; 64%). Cutting behaviors reported as suicide attempts were not considered.
Separate reviews were conducted by two authors (AS and JK) blind to patients responses
to assessment measures. Discrepancies (n = 43) were resolved by a third independent rater
(JD).

Childrens Interview for Psychiatric Symptoms (ChIPS) [27]

The ChIPS is a structured clinical interview that screens for 20 DSM-IV Axis I dis-
orders. Validation studies demonstrate adequate sensitivity and specificity in relation to
clinician diagnoses as well as concurrent validity in comparison to the DICA [27] and
to the K-SADS-PL [28]. Consensus DSM-IV diagnoses were made by a clinical team
using the results of the ChIPS and all available clinical data (i.e., the full assessment
battery and the complete medical record). Similar best-estimate clinical consensus
procedures have been shown to yield good to excellent reliability [29, 30].

Suicide Probability Scale (SPS) [31]

The SPS is a 36-item self-report measure of feelings/behavior related to suicidality. Items

are rated on a 4-point scale ranging from none or little of the time to most or all of the
time. The SPS yields a total score and four subscales (i.e., hopelessness, suicidal ideation,
negative self-evaluation, and hostility). Higher scores indicate greater suicidality. The SPS
has adequate internal consistency (total score a = .93; subscale as = .62.89), split-half
reliability (r = .93), and testretest reliability (r = .92) [31].

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Reynolds Adolescent Depression Scale-2 (RADS-2) [32]

The RADS-2 is a 30-item self-report measure of depressive symptoms. Items are rated on
4-point scale ranging from almost never to most of the time and are summed to create
a total symptoms score. The RADS-2 has shown adequate internal consistency (a = .92)
and testretest reliability (r = .80) [32].

Self-Perception Profile for Children (SPPC) [33]

The SPPC is a 28-item self-report measure assessing perceived competence and self-worth
with five subscales: social acceptance, athletic competence, physical appearance, romantic
appeal, and close friendships. The subscales have shown adequate internal consistency
(subscale as = .85.95) [33].

Trauma Symptom Checklist for Children (TSCC) [34]

The TSCC is a 55-item measure assessing trauma-related symptoms. Items are rated on a
4-point rating scale. The measure yields two validity scales (i.e., under-reporting, hyper-
reporting) and six clinical scales (i.e., anxiety, depression, anger, posttraumatic stress,
dissociation [with two subscales: overt and fantasy], and sexual concerns [with two sub-
scales: preoccupations and distress]). Research conducted by the developers has shown
adequate internal consistency (subscale as = .82.89) as well as evidence for construct and
convergent validity [34].

Hopelessness Scale for Children (HSC) [35]

The HSC includes 17 true/false statements assessing negative expectancies about oneself
and ones future, with higher scores indicating increased hopelessness. Research conducted
by the developers of the inventory reported internal consistency a = .97 and testretest
reliability r = .52. The HSC also has shown adequate construct validity with child and
adolescent psychiatric patients [35, 36].

Multidimensional Anxiety Scale for ChildrenShort Version (MASC-10) [37]

The MASC-10 is a 10-item rating scale that screens for physical symptoms of anxiety,
harm avoidance, social anxiety, and separation/panic. Items are rated on a 4-point rating
scale ranging from never true about me to often true about me. The MASC-10 has
adequate internal consistency (a = .87) and testretest reliability (r = .83) [37].

State-Trait Anger Expression Inventory (STAXI) [38]

The STAXI is a 44-item, 4-point rating scale assessing control of and expression of anger.
Items are rated on a 4-point scale, with higher scores indicating greater intensity/frequency
of anger experienced or expressed. The measure consists of seven subscales (i.e., state
anger, trait anger, angry temperament, angry reaction, anger in, anger out, and anger
control) as well as an index of anger expression frequency. Adequate psychometric
properties have been reported, and the inventory has been validated with both normal and
clinical populations [38].

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Results

In the first major subsection of the Results presented below, the representativeness of the
sample retained for analyses is examined. Potential demographic differences among the
three cutting group classifications (i.e., Noncutters, Subthreshold, and Threshold) also are
examined in this section. Next, cutting group differences in risk for Axis I psychiatric
diagnoses were tested. Third, cutting group differences in suicidality were examined. In the
fourth subsection, potential cutting group differences in self-reported psychiatric impair-
ment were examined.

Representativeness of the Retained Sample

A series of t-tests and chi-square analyses were conducted to assess demographic differ-
ences between participants who were included in this study (n = 288) versus those who
were excluded (n = 113). No differences were evident for sex (v2 [2] = 1.18, p = 0.28),
age (F [1, 399] = .20, p = 0.65), or race/ethnicity (i.e., white vs. nonwhite; v2 [2] = 2.26,
p = 0.13).
Analyses also compared the Noncutting, Subthreshold, and Threshold cutting groupings
on sex, age, and race/ethnicity. No differences were evident for age (F [2, 287] = .28,
p = 0.75), or race/ethnicity (i.e., white vs. nonwhite; v2 [2] = 4.05, p = 0.13). Girls were
more likely to be classified as Subthreshold and Threshold cutters than were boys (79%
and 80% female, respectively) compared to the Noncutting group (55% female), v2
(2) = 17.90, p \ 0.001.

Psychiatric Diagnoses and Cutting Behavior

Table 1 presents the frequencies of DSM-IV diagnoses for the three cutting groupings.
Anxiety disorders were relatively rare (ranging from 0.3% for Phobia to 2.8% for Gen-
eralized Anxiety Disorder). Therefore, diagnoses of Generalized Anxiety Disorder,
Obsessive Compulsive Disorder, Phobia, Social Phobia, Separation Anxiety Disorder,
Panic Disorder, and Anxiety Disorder NOS were aggregated into an Anxiety Disorders
composite.
Cutting group differences in psychiatric diagnoses were evaluated using logistic
regressions controlling for gender. Adolescents in the Threshold group were more likely
than those in the Noncutting group to meet criteria for Major Depression, Wald v2
(1) = 4.05, p \ 0.05 (see Table 1). The Subthreshold group did not differ from either the
Threshold (Wald v2 [1] = 1.11, p = 0.29) or the Noncutting groups (Wald v2 [1] = .33,
p = 0.57) in risk for being diagnosed with Major Depression.
Adolescents in the Subthreshold cutting group were at significantly greater risk for
being diagnosed with Posttraumatic Stress Disorder (PTSD) compared to the Noncutting
group, Wald v2 (1) = 5.59, p \ 0.05. The Threshold group did not differ from either the
Subthreshold (Wald v2 [1] = 1.27, p = 0.26) or the Noncutting groups (Wald v2
[1] = 1.44, p = 0.23) in risk for being diagnosed with PTSD.
Adolescents in the Threshold group were significantly more likely than the Noncutting
group to meet criteria for an eating disorder, Wald v2 (1) = 1.01, p \ 0.01. The Sub-
threshold group did not differ from the Threshold group (Wald v2 [1] = .56, p = 0.46),
and the differences between the Noncutting and the Subthreshold groups approached but
did not reach significance, Wald v2 (1) = 3.71, p = 0.054. However, it should be noted

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Table 1 Prevalence rates of psychiatric diagnoses of the noncutting, subthreshold, and threshold cutting groups (n = 288)
Noncutting Subthreshold Threshold Subthreshold vs. Threshold vs. Subthreshold vs.
N (%) N (%) N (%) Noncutting Noncutting Threshold
Odds ratio Odds ratio Odds ratio
(95% CI) (95% CI) (95% CI)

Major depression 49 (26.8) 16 (37.2) 27 (44.3) 1.27 (.562.90) 2.06 (1.024.18) 1.62 (.663.99)
Bipolar disorder 24 (13.1) 5 (11.6) 10 (16.7) 1.06 (.353.20) 1.20 (.473.08) 1.33 (.343.81)
Any anxiety disorder 37 (20.2) 10 (23.3) 11 (18.0) .87 (.342.25) .65 (.271.59) .75 (.242.32)
Posttraumatic stress disorder 36 (19.6) 15 (34.9) 14 (23.0) 2.82 (1.196.66) 1.65 (.733.71) .58 (.231.49)
Eating disorder 1 (0.5) 3 (7.0) 7 (11.5) 9.58 (.9695.45) 16.50 (1.97138.31) 1.72 (.417.20)
Attention-deficit/hyperactivity disorder 38 (20.8) 7 (16.2) 13 (21.3) 1.74 (.545.62) 2.59 (.986.88) 1.49 (.464.82)
Oppositional defiant disorder 21 (11.5) 6 (14.0) 4 (6.6) 1.11 (.284.46) 1.02 (.293.58) .92 (.194.39)
Conduct disorder 30 (16.4) 2 (4.7) 5 (8.2) .35 (.042.89) .24 (.031.97) .69 (.0411.39)
Substance abuse 19 (10.4) 5 (11.6) 12 (19.7) 1.35 (.394.70) 2.28 (.846.16) 1.69 (.476.01)

Notes: Consensus diagnoses, using DSM-IV criteria were made by a clinical team using all available data, including the Childrens Interview for Psychiatric Syndromes and
each participants complete medical record. Any Anxiety Disorder aggregates diagnoses of Generalized Anxiety Disorder, Obsessive Compulsive Disorder, Phobia, Social
Phobia, Separation Anxiety Disorder, Panic Disorder, and Anxiety Disorder NOS. Odds ratios were calculated in logistic regressions controlling for gender. Odds ratios that
are bolded are significant at p \ 0.05
Child Psychiatry Hum Dev (2008) 39:427438
Child Psychiatry Hum Dev (2008) 39:427438 433

Table 2 Suicidality of the noncutting, subthreshold, and threshold cutting groups (n = 288)
Noncutting Subthreshold Threshold Subthreshold Threshold vs. Subthreshold
N (%) N (%) N (%) vs. Noncutting Noncutting vs. Threshold
Odds ratio Odds ratio Odds ratio
(95% CI) (95% CI) (95% CI)

Suicidality on admission
Ideator/ 63 (41.4) 22 (56.4) 30 (66.7) 1.12 (.482.62) 1.94 (.844.50) 1.74 (.634.78)
threatener
Attemptera 29 (16.0) 2 (4.9) 11 (19.6)
Lifetime history 19 (10.4) 5 (11.6) 12 (19.7) .69 (.301.61) 1.38 (.682.83) 1.99 (.785.12)
of 1+ suicide
attempts
Repeated (2+) 26 (44.8) 6 (50.0) 14 (50.0) .74 (.262.18) 1.25 (.542.88) 1.68 (.535.37)
attempts
a
Potential group differences were not tested as the Subthreshold grouping included \5 participants

that all of the participants diagnosed with an eating disorder (n = 11) were female, and
recall that girls were more likely to cut than were boys.
There were no significant differences in the prevalence rates of Bipolar Disorder, Anxiety
Disorders, Attention-Deficit/Hyperactivity Disorder, ODD, CD, or Substance Abuse. Also,
none of the gender by cutting interaction terms significantly predicted any psychiatric
diagnosis (all Wald v2s \ 3.50, all ps C .18). In addition, the cutting groups did not differ
on the overall number of DSM-IV diagnoses identified, F (2, 281) = 2.00, p = 0.14
(MNoncutting = 1.56 [SD = .85], MSubthreshold = 1.79 [SD = .80], MThreshold = 1.75
[SD = .96]).

Suicidality and Cutting Behavior

Logistic regressions, controlling for gender, were conducted to examine differences

between the Noncutting, Subthreshold, and Threshold groupings for current suicidality and
for lifetime suicide attempts (see Table 2). The cutting groups were not found to differ
significantly in suicidal ideation at time of admission, in history of attempted suicide, or in
history of repeat (2+) suicide attempts (all Wald v2s \ 2.39, all ps C .12). In addition, the
gender by cutting group interaction did not predict any index of suicidality (all Wald
v2s \ 1.58, all ps C .45).

Self-Reported Impairment and Cutting Behavior

A series of 2 (GenderMale/Female) 9 3 (CuttingNoncutting, Subthreshold,

Threshold) way ANOVAs were conducted to assess cutting group differences in self-
reported psychological impairment (see Table 3). Significance for these analyses was
set at p \ 0.001 to control for Type I error. Results demonstrated that adolescents in
the Threshold group scored significantly higher than the Noncutting group on the SPS
hopelessness and suicidal ideation subscales, the SPS total score, the RADS, and on the
TSCC depression and dissociation subscales. Of note, the Subthreshold group did not
differ from the Threshold or the Noncutting groupings on any self-report measure of
impairment. In addition, the gender by cutting group interaction term did not signifi-
cantly predict any index of self-reported impairment.

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Table 3 Means, standard deviations, and Ns for the self-report measures of impairment by cutting group
Noncutting Sub-threshold Threshold F

M SD N M SD N M SD N

Suicide probability scale

Hopelessness 58.0 11.7 169 60.8 12.0 40 65.3 8.5 61 11.11*
Suicide ideation 58.3 12.2 169 60.4 12.5 40 65.9 11.7 61 9.97*
Negative SE 61.7 11.1 169 61.1 11.9 40 64.0 9.1 61 1.50
Hostility 56.5 12.0 169 57.8 10.2 40 61.5 11.4 61 6.28
Total 61.2 11.6 169 63.1 12.7 40 68.0 9.2 61 9.40*
Reynolds adolescent depression scale 52.9 13.2 169 56.5 14.5 40 61.8 12.6 60 7.84*
Self-perception profile for children
Social acceptance 3.0 0.8 161 2.8 1.0 37 2.9 0.8 57 0.74
Athletic competence 2.6 0.9 161 2.3 0.9 37 2.4 1.5 57 1.06
Physical appeal 2.6 0.9 161 2.2 1.0 37 2.3 0.9 57 1.49
Romantic appeal 2.7 0.9 161 2.6 0.7 37 2.5 0.7 57 0.39
Close friendships 3.4 3.2 161 3.1 0.9 37 2.9 0.8 57 0.94
Trauma symptom checklist for children
Under-reporting 53.2 11.3 170 51.4 12.1 39 48.7 10.1 60 4.09
Hyper-reporting 50.2 9.7 171 51.2 8.9 39 54.5 13.7 60 2.57
Anxiety 48.4 11.2 171 50.0 10.9 39 53.3 11.0 60 4.01
Depression 52.4 12.1 171 54.8 12.7 39 60.0 11.7 60 9.19*
Anger 48.9 10.3 171 48.5 10.1 39 51.9 10.6 60 3.28
PTSD 47.3 10.9 171 50.6 13.0 39 52.4 10.3 60 5.62
Dissociation 48.9 11.1 171 50.1 11.6 39 55.2 13.1 60 6.70*
DissociationOvert 49.9 11.8 171 51.0 12.2 39 55.5 13.1 60 5.43
DissociationFantasy 47.1 9.5 171 47.9 10.9 39 51.9 12.2 60 4.57
Sexual Concerns 50.9 16.8 171 57.1 23.6 39 55.3 19.2 60 0.73
Sexual concernsPreoccupations 50.9 16.7 171 57.1 23.0 39 54.2 20.2 60 0.69
Sexual concernsDistress 51.3 16.3 171 53.3 20.1 39 54.4 18.2 60 0.41
Hopelessness scale for children 4.8 4.5 165 5.7 5.0 39 7.2 5.2 57 6.15
Multidimensional anxiety scale for children 49.5 13.2 170 50.2 12.3 38 54.0 14.6 60 1.69
State/trait anger expression inventory
State anger 53.4 9.2 167 52.2 5.9 38 55.2 8.7 59 1.89
Trait anger 43.0 14.5 166 42.0 14.8 39 45.0 14.6 59 1.53
Angry temperament 49.9 12.7 167 49.4 11.7 39 51.2 13.0 59 1.31
Angry reaction 42.2 13.1 166 42.2 16.7 39 44.0 13.0 59 0.87
Anger in 43.9 12.3 167 45.5 12.1 39 49.5 9.6 59 2.00
Anger expression 51.8 12.8 167 50.7 12.5 39 52.0 10.5 59 1.28
Anger control 48.9 10.6 167 51.0 10.2 39 50.7 10.4 59 0.64
Anger expression frequency 49.0 13.1 166 48.1 12.6 39 50.6 11.4 59 1.23

Note: Significance was set at p \ 0.001 to control for Type I error. Statistically significantly differences
between the Noncutting and the Threshold Cutting Groups are bolded. The Subthreshold group did not
significantly differ from either the Noncutting or Threshold groups for any self-reported index of impair-
ment. * p \ 0.001

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Discussion

The present study examined cutting behavior in adolescent psychiatric inpatients and
compared subgroups of adolescents with differing histories of cutting behavior on DSM-IV
diagnoses, on suicidal ideation and behavior, and on self-report measures of impairment.
Approximately 36% of the adolescent inpatients had documented histories of recent (i.e.,
within the past 2 years) cutting behaviors. Of these, 59% (21% of the total sample)
exhibited recurrent or severe (i.e., wounds requiring medical intervention) cutting. The
prevalence of cutting in the current sample is comparable to rates observed in other
adolescent inpatient samples (e.g., 2638%) [12, 23] and significantly higher than rates
seen in community-based adolescent populations (e.g., 1.714%) [13, 15].
The results indicated that adolescents with a more extensive degree of self-cutting (i.e.,
Threshold cutters) evidenced more symptoms of depression and trauma-related dissocia-
tion and were more likely to be diagnosed with Major Depression relative to adolescents
who do not engage in cutting. These results are largely consistent with the growing body of
literature examining adolescent NSSI and with evidence showing that a primary reason for
engaging in NSSI behaviors is to reduce feelings of depression or negative affect [8, 12, 13,
23]. Importantly, the inclusion of a non-harming control group from the same psychiatric
facility helps to ensure that these results were not due to potential differences in psy-
chological distress more generally.
Although adolescents in the Threshold cutting group reported higher levels of suicidal
ideation on the SPS relative to the Noncutting group, the cutting groups were not found to
differ with regard to suicidal behavior. These findings are consistent with work by Mu-
ehlenkamp and Gutierrez [39], who found that adolescents with a history of NSSI reported
a greater attraction to life relative to adolescents with a history of suicidal behavior.
Relatedly, Patton and colleagues [15] found that most adolescents who engage in some
form of NSSI do not perceive death as a likely result of their self-harming behavior. The
lack of cutting group differences in suicidal behavior evident in the present research are in
line with these prior findings and provide further support for the distinction between NSSI
and suicidality [2, 6, 40, 41].
Adolescents with limited histories of cutting (i.e., the Subthreshold group) generally did
not differ from either the noncutters or those with more extensive cutting histories. However,
adolescents in the Subthreshold cutting group were nearly three times as likely to meet
diagnostic criteria for PTSD relative to the adolescent inpatients with no history of cutting
behavior. Relations between experiencing abuse or a trauma and NSSI have been found in
similar studies [20]. It is unclear why adolescents engaging in more severe or repetitive
cutting (i.e., Threshold cutters) did not exhibit increased risk for PTSD. One possibility is that
cutting may initially be undertaken as maladaptive coping strategy for dealing with childhood
trauma. As cutting becomes increasingly repetitive, however, alternate motivations (such as
negative affect regulation [23], or potentially addictive aspects of repetitive NSSI [12]) may
become the primary forces compelling continued cutting behavior.
The findings also have implications for understanding relations between gender and
cutting. In the present study females were significantly more likely to have documented
histories of cutting than were boys. This finding is consistent with some prior research
using both community-based [e.g., 9, 15] and clinical adolescent samples [e.g., 7]. How-
ever, other studies have found males were as likely as females to engage in NSSI [1214,
22, 23]. One possibility for these discrepant findings may derive from the considerable
variation across studies in the behaviors categorized as NSSI [e.g., 13], whereas the present
study focused specifically on cutting (a method of NSSI hypothesized to be particularly

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common among psychiatrically-impaired females) [41]. Importantly, the psychiatric cor-

relates of cutting behavior were found to be similar for female and male cutters (i.e., all of
the gender X cutting group interaction terms were nonsignificant). Cumulatively these
findings suggest that, although important gender differences exist with regards to preva-
lence, the consequences of cutting behavior may act independently of whether the
adolescent in question is male or female.

Limitations

A few limitations should be noted. First, the sample was limited to adolescents admitted to
a psychiatric unit. Second, the assessment of cutting behavior (i.e., archival chart review)
precluded the collection of other factors of import for understanding self-cutting, such as
the motivations for engaging in NSSI [1, 17, 25] or the contextual features associated with
the cutting episodes. Third, this study did not consider Axis II diagnoses. Features of
personality disorders, in particular characteristics of Borderline Personality Disorder, are
common in adults who self-injure [2, 41], and recent evidence finds elevated rates of axis II
symptomatology among female adolescent inpatients who engage in NSSI [14]. Future
research could build upon the present findings by evaluating whether adolescents who
engage in differing degrees of cutting behavior evidence differing risk for an Axis II
diagnosis. Fourth, the investigation was cross-sectional; the direction of effects could not
be ascertained. In addition, the focus on cutting precluded examining whether adolescents
engaged in other types of NSSI (e.g., burning) during the time frame considered. Further
work employing a prospective design could clarify temporal relations as well as the
psychiatric course of adolescents who differ in cutting behavior while controlling for
additional methods of NSSI. It should also be noted that the small sample size available for
analyses precluded examining differences across specific racial or ethnic groups.

Summary

The psychiatric correlates of engaging in differing levels of cutting were examined in this
archival study of 288 adolescent psychiatric patients. Results indicated that both male and
female adolescent inpatients with more extensive histories of cutting (i.e., Threshold cutters)
were more likely to be diagnosed with Major Depression and reported greater suicidality and
trauma-related symptoms of depression and dissociation relative to adolescent inpatients
with no history of cutting (i.e., the Noncutting group). Of note, adolescents with relatively
limited histories of cutting (i.e., the Subthreshold group) did not differ from either the
Threshold or the Noncutting groupings except for an elevated risk for PTSD compared to the
Noncutting group. This pattern suggests that psychiatric impairment may become progres-
sively more evident as cutting behavior becomes increasingly repetitive and/or severe.
Alternatively, it is possible that increased psychiatric impairment may result in a subgroup of
adolescents (i.e., Threshold cutters) who repeatedly use cutting as a maladaptive coping
strategy for dealing with distress. Intervening with adolescents who engage in cutting early in
their self-harming trajectory (e.g. providing more effective strategies to cope with negative
affect) may help prevent an escalation in their self-injurious behavior.

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