Prominent theories suggest that self-injurious thoughts and behaviours are negatively reinforced by decreased negative affect. The present meta-analysis quantifies effects from intensive longitudinal studies measuring negative affect and self-injurious thoughts and behaviours. We obtained data from 38 of the 79 studies (48%, 22 unique datasets) involving N = 1,644 participants (80% female, 75% white). Individual-participant data meta-analyses revealed changes in affect pre/post self-injurious thoughts and behaviours. In antecedent models, results supported increased negative affect before nonsuicidal self-injurious behaviour (k = 14, 95% CI 0.09 to 0.31) and suicidal thoughts (k = 14, 95% CI 0.03 to 0.19). For consequence models, negative affect was reduced following nonsuicidal self-injurious thoughts (k = 6, 95% CI −0.79 to −0.44), nonsuicidal self-injurious behaviours (k = 14, 95% CI −0.73 to −0.19) and suicidal thoughts (k = 13, 95% CI −0.79 to −0.23). Findings, which were not moderated by sampling strategies or sample composition, support the affect regulation function of self-injurious thoughts and behaviours.
This is a preview of subscription content, access via your institution
Access Nature and 54 other Nature Portfolio journals
Get Nature+, our best-value online-access subscription
$29.99 / 30 days
cancel any time
Subscribe to this journal
Receive 12 digital issues and online access to articles
$119.00 per year
only $9.92 per issue
Rent or buy this article
Prices vary by article type
Prices may be subject to local taxes which are calculated during checkout
Although this study was not preregistered, the raw data are publicly available at https://github.com/kskuehn/NA-SITB_meta.
Analysis scripts are also publicly available at https://github.com/kskuehn/NA-SITB_meta.
Suicide rate estimates, age-standardized estimates by WHO region. Global Health Observatory Data Repository, World Health Organization https://apps.who.int/gho/data/node.main.MHSUICIDEASDR?lang=en (2021).
Substance Abuse and Mental Health Services Administration. Key substance use and mental health indicators in the United States: results from the 2019 national survey on drug use and health (HHS publication no. PEP20-07-01-001, NSDUH Series H-55). Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration https://www.samhsa.gov/data/ (2020).
Nock, M. K. Self-injury. Annu. Rev. Clin. Psychol. 6, 339–363 (2010).
Whitlock, J. et al. Nonsuicidal self-injury as a gateway to suicide in young adults. J. Adolesc. Health 52, 486–492 (2010).
Gillies, D. et al. Prevalence and characteristics of self-harm in adolescents: meta-analyses of community-based studies 1990–2015. J. Am. Acad. Child Adolesc. Psychiatry 57, 733–741 (2018).
Franklin, J. C. et al. Risk factors for suicidal thoughts and behaviors: a meta-analysis of 50 years of research. Psychol. Bull. 143, 187–232 (2017).
Nock, M. K. & Prinstein, M. J. A functional approach to the assessment of self-mutilative behavior. J. Consult. Clin. Psychol. 72, 885–890 (2004).
Chapman, A. L., Gratz, K. L. & Brown, M. Z. Solving the puzzle of deliberate self-harm: the experiential avoidance model. Behav. Res. Ther. 44, 371–394 (2006).
Kleiman, E. M. et al. Are suicidal thoughts reinforcing? A preliminary real-time monitoring study on the potential affect regulation function of suicidal thinking. J. Affect. Disord. 232, 122–126 (2018).
Berking, M. & Lukas, C. A. The affect regulation training (ART): a transdiagnostic approach to the prevention and treatment of mental disorders. Curr. Opin. Psychol. 3, 64–69 (2015).
Levitt, J. T. & Cloitre, M. A clinician’s guide to STAIR/MPE: treatment for PTSD related to childhood abuse. Cogn. Behav. Pract. 12, 40–52 (2005).
Linehan, M. M. Cognitive-Behavioral Treatment of Borderline Personality Disorder (Guilford Press, 1993).
Stasiewicz, P. R. et al. Affect regulation training (ART) for alcohol use disorders: development of a novel intervention for negative affect drinkers. J. Subst. Abus. Treat. 45, 433–443 (2013).
Neacsiu, A. D., Bohus, M. & Linehan, M. M. in Handbook of Emotion Regulation (ed. Gross, J. J.) 491–507 (Guilford Press, 2014).
Taylor, P. J. et al. A meta-analysis of the prevalence of different functions of non-suicidal self-injury. J. Affect. Disord. 227, 759–769 (2018).
Littlefield, A. K., Talley, A. E. & Jackson, K. M. Coping motives, negative moods, and time-to-drink: exploring alternative analytic models of coping motives as a moderator of daily mood-drinking covariation. Addict. Behav. 37, 1371–1376 (2012).
Bradburn, N. M., Rips, L. J. & Shevell, S. K. Answering autobiographical questions: the impact of memory and inference on surveys. Science 236, 157–161 (1987).
Eysenck, M. W. & Mogg, K. in The Handbook of Emotion and Memory: Research and Theory (ed. Christianson, S. A.) 429–450 (Psychology Press, 1992).
Blyth, C. R. On Simpson’s paradox and the sure-thing principle. J. Am. Stat. Assoc. 67, 364–366 (1972).
Curran, P. J. & Bauer, D. J. The disaggregation of within-person and between-person effects in longitudinal models of change. Annu. Rev. Psychol. 62, 583–619 (2011).
Reitz, S. et al. Incision and stress regulation in borderline personality disorder: neurobiological mechanisms of self-injurious behaviour. Br. J. Psychiatry 207, 165–172 (2015).
Welch, S. S., Linehan, M. M., Sylvers, P., Chittams, J. & Rizvi, S. L. Emotional responses to self-injury imagery among adults with borderline personality disorder. J. Consult. Clin. Psychol. 76, 45–51 (2008).
Franklin, J. C. et al. The functions of nonsuicidal self-injury: support for cognitive–affective regulation and opponent processes from a novel psychophysiological paradigm. J. Abnorm. Psychol. 119, 850–862 (2008).
Kleiman, E. M. & Nock, M. K. Real-time assessment of suicidal thoughts and behaviors. Curr. Opin. Psychol. 22, 33–37 (2018).
Kiekens, G., Robinson, K., Tatnell, R. & Kirtley, O. J. Opening the black box of daily life in nonsuicidal self-injury research: with great opportunity comes great responsibility. JMIR Ment. Health 8, e30915 (2021).
Kleiman, E. M. et al. Digital phenotyping of suicidal thoughts. Depress. Anxiety 35, 601–608 (2018).
King, K. M. et al. Longitudinal modeling in developmental neuroimaging research: common challenges, and solutions from developmental psychology. Dev. Cogn. Neurosci. 33, 54–72 (2018).
Armey, M. F., Crowther, J. H. & Miller, I. W. Changes in ecological momentary assessment reported affect associated with episodes of nonsuicidal self-injury. Behav. Ther. 42, 579–588 (2011).
Bresin, K., Carter, D. L. & Gordon, K. H. The relationship between trait impulsivity, negative affective states, and urge for nonsuicidal self-injury: a daily diary study. Psychiatry Res. 205, 227–231 (2013).
Kiekens, G. et al. Fluctuations in affective states and self-efficacy to resist non-suicidal self-injury as real-time predictors of non-suicidal self-injurious thoughts and behaviors. Front. Psychiatry 11, 214 (2020).
Borenstein, M., Hedges, L. V., Higgins, J. P. T. & Rothstein, H. R. Introduction to Meta-Analysis (Wiley, 2021).
Friedman, L. Why vote-count reviews don’t count. Biol. Psychiatry 49, 161–162 (2001).
Hamza, C. A. & Willoughby, T. Nonsuicidal self‐injury and affect regulation: recent findings from experimental and ecological momentary assessment studies and future directions. J. Clin. Psychol. 71, 561–574 (2015).
Hepp, J. et al. A systematic review of daily life studies on non-suicidal self-injury based on the four-function model. Clin. Psychol. Rev. 82, 101888 (2020).
Rodríguez-Blanco, L., Carballo, J. J. & Baca-Garcia, E. Use of ecological momentary assessment (EMA) in non-suicidal self-injury (NSSI): a systematic review. Psychiatry Res. 263, 212–219 (2018).
Sedano-Capdevila, A., Porras-Segovia, A., Bello, H. J., Baca-García, E. & Barrigon, M. L. Use of ecological momentary assessment to study suicidal thoughts and behavior: a systematic review. Curr. Psychiatry Rep. 23, 1–17 (2021).
Gee, B. L., Han, J., Benassi, H. & Batterham, P. J. Suicidal thoughts, suicidal behaviours and self-harm in daily life: a systematic review of ecological momentary assessment studies. Digital Health 6, 2055207620963958 (2020).
Rabasco, A. & Sheehan, K. The use of intensive longitudinal methods in research on suicidal thoughts and behaviors: a systematic review. Arch. Suicide Res. 1–15 (2021).
Nock, M. K. Why do people hurt themselves? New insights into the nature and functions of self-injury. Curr. Dir. Psychol. Sci. 18, 78–83 (2009).
Peters, E. M. et al. Instability of suicidal ideation in patients hospitalized for depression: an exploratory study using smartphone ecological momentary assessment. Arch. Suicide Res. 26, 1–14 (2020).
Vansteelandt, K. et al. The affect stabilization function of nonsuicidal self-injury in borderline personality disorder: an ecological momentary assessment study. Behav. Res. Ther. 92, 41–50 (2017).
Houben, M. et al. The emotion regulation function of nonsuicidal self-injury: a momentary assessment study in inpatients with borderline personality disorder features. J. Abnorm. Psychol. 126, 89 (2017).
Santangelo, P. S. et al. Ecological momentary assessment of affective and interpersonal instability in adolescent non-suicidal self-injury. J. Abnorm. Child. Psych. 45, 1429–1438 (2017).
Wolford-Clevenger, C. A daily diary study of intrusive PTSD symptoms and suicidal ideation among transgender and gender diverse adults. Psychol. Trauma-US 13, 768–771 (2017).
Muehlenkamp, J. J. et al. Emotional states preceding and following acts of non-suicidal self-injury in bulimia nervosa patients. Behav. Res. Ther. 47, 83–87 (2009).
Hochard, K. D., Heym, N. & Townsend, E. The unidirectional relationship of nightmares on self-harmful thoughts and behaviors. Dreaming 25, 44–58 (2015).
Czyz, E. K., King, C. A. & Nahum-Shani, I. Ecological assessment of daily suicidal thoughts and attempts among suicidal teens after psychiatric hospitalization: lessons about feasibility and acceptability. Psychiat. Res. 267, 566–574 (2018).
Selby, E. A., Franklin, J., Carson-Wong, A. & Rizvi, S. L. Emotional cascades and self-injury: investigating instability of rumination and negative emotion. J. Clin. Psychol. 69, 1213–1227 (2013).
Selby, E. A. et al. The dynamics of pain during nonsuicidal self-injury. Clin. Psychol. Sci. 7, 302–320 (2019).
Lear, M. K., Wilkowski, B. M. & Pepper, C. M. A daily diary investigation of the defective self-model among college students with recent self-injury. Behav. Ther. 50, 1002–1012 (2019).
Husky, M. et al. Predictors of daily life suicidal ideation in adults recently discharged after a serious suicide attempt: a pilot study. Psychiat. Res. 256, 79–84 (2017).
Kaurin, A., Dombrovski, A.Y., Hallquit, M.N. & Wright, A.G. Momentary interpersonal processes of suicidal surges in borderline personality disorder. Psychol. Med. 1–11 (2020).
Kaurin, A., Dombrovski, A., Hallquist, M. & Wright, A. G. Daily suicidal surge and attempted suicide in borderline personality disorder. Preprint at https://doi.org/10.31234/osf.io/hswea
Forkmann, T. et al. Assessing suicidality in real time: a psychometric evaluation of self-report items for the assessment of suicidal ideation and its proximal risk factors using ecological momentary assessments. J. Abnorm. Psych. 127, 758–769 (2018).
Kleiman, E. M. et al. Examination of real-time fluctuations in suicidal ideation and its risk factors: results from two ecological momentary assessment studies. J. Abnorm. Psych. 126, 726–738 (2017).
Kleiman, E. M. et al. Examination of real-time fluctuations in suicidal ideation and its risk factors: results from two ecological momentary assessment studies. J. Abnorm. Psychol. 126, 726–738 (2017).
Salim, S., Robinson, M. & Flanders, C. E. Bisexual women’s experiences of microaggressions and micro affirmations and their relation to mental health. Psychol. Sex. Orientat. Gend. Divers. 6, 336 (2019).
Hochard, K. D., Ashcroft, S., Carroll, J., Heym, N. & Townsend, E. Exploring thematic nightmare content and associated self‐harm risk. Suicide Life Threat. Behav. 49, 64–75 (2019).
Mou, D. et al. Negative affect is more strongly associated with suicidal thinking among suicidal patients with borderline personality disorder than those without. J. Psychiatr. Res. 104, 198–201 (2018).
King, K. M., Feil, M. C. & Halvorson, M. A. Negative urgency is correlated with the use of reflexive and disengagement emotion regulation strategies. Clin. Psychol. Sci. 6, 822–834 (2018).
Czyz, E. K. et al. Self‐efficacy to avoid suicidal action: factor structure and convergent validity among adults in substance use disorder treatment. Suicide Life Threat. Behav. 44, 698–709 (2014).
Anestis, M. D., Pennings, S. M., Lavender, J. M., Tull, M. T. & Gratz, K. L. Low distress tolerance as an indirect risk factor for suicidal behavior: considering the explanatory role of non-suicidal self-injury. Compr. Psychiatry 54, 996–1002 (2013).
Versluis, A., Verkuil, B., Spinhoven, P., van der Ploeg, M. M. & Brosschot, J. F. Changing mental health and positive psychological well-being using ecological momentary interventions: a systematic review and meta-analysis. J. Med. Internet Res. 18, e152 (2016).
Kirtley, O. J., Lafit, G., Achterhof, R., Hiekkaranta, A. P. & Myin-Germeys, I. Making the black box transparent: a template and tutorial for registration of studies using experience-sampling methods. Adv. Methods Pract. Psychol. Sci. 4, 2515245920924686 (2021).
Sliwinski, M. J. Measurement‐burst designs for social health research. Soc. Personal. Psychol. Compass 2, 245–261 (2008).
King, C. A. et al. Five profiles of adolescents at elevated risk for suicide attempts: differences in mental health service use. J. Am. Acad. Child Adolesc. Psychiatry 59, 1058–1068 (2020).
Kaurin, A., Dombrovski, A. Y., Hallquist, M. N. & Wright, A. G. Integrating a functional view on suicide risk into idiographic statistical models. Behav. Res. Ther. 150, 104012 (2021).
Kuehn, K. S., Foster, K. T., Czyz, E. & King, C. A. Identifying person-specific coping responses to suicidal urges: a case series analysis and illustration of the idiographic method. Suicide Life Threat. Behav. https://doi.org/10.1111/sltb.12841 (2022).
Wright, A. G. & Woods, W. C. Personalized models of psychopathology. Annu. Rev. Clin. Psychol. 16, 49–74 (2020).
Foster, K. T. & Beltz, A. M. Advancing statistical analysis of ambulatory assessment data in the study of addictive behavior: a primer on three person-oriented techniques. Addict. Behav. 83, 25–34 (2018).
Moher, D. et al. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med. 6, e1000097 (2009).
Riley, R. D., Lambert, P. C. & Abo-Zaid, G. Meta-analysis of individual participant data: rationale, conduct, and reporting. Br. Med. J. 340, c221–c227 (2010).
Enders, C. K. & Tofighi, D. Centering predictor variables in cross-sectional multilevel models: a new look at an old issue. Psychol. Methods 12, 121 (2007).
Gelman, A., Simpson, D. & Betancourt, M. The prior can often only be understood in the context of the likelihood. Entropy 19, 555–567 (2017).
Bürkner, P. C. brms: an R package for Bayesian multilevel models using Stan. J. Stat. Softw. https://www.jstatsoft.org/v080/i01 (2017).
R Core Team: R: a language and environment for statistical computing (R Foundation for Statistical Computing, 2013).
This research was supported by a National Research Service Award from the National Institute of Mental Health (F31MH117827, PI K.S.K.). The funders had no role in study design, data collection and analysis, decision to publish or preparation of the manuscript.
The authors thank the many individuals who contributed to this manuscript by sharing their data. We are grateful for their generosity and hope this work assists in our collective efforts to reduce the global burden of self-injury.
The authors declare no competing interests.
Peer review information
Nature Human Behaviour thanks Glenn Kiekens, Raffaella Calati and the other, anonymous, reviewer(s) for their contribution to the peer review of this work. Peer reviewer reports are available.
Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
About this article
Cite this article
Kuehn, K.S., Dora, J., Harned, M.S. et al. A meta-analysis on the affect regulation function of real-time self-injurious thoughts and behaviours. Nat Hum Behav 6, 964–974 (2022). https://doi.org/10.1038/s41562-022-01340-8
This article is cited by
Nature Reviews Psychology (2023)