1. Introduction

Non-suicidal self-injury (NSSI) is the intentional and direct injuring of one’s own body without suicidal intent (ISSS, n.d.). Lifetime prevalence of NSSI in the community varies from approximately 6% of adults (Klonsky, 2011) to 15-17% of adolescents and university students (Laye-Gindhu and Schonert-Reichl, 2005; Whitlock and Knox, 2007; Nixon et al., 2008), while rates among clinical populations range from 20% (adults; Briere and Gil, 1998) to over 60% (adolescents; DiClemente et al., 1991; Nock & Prinstein, 2004). Despite increased attention to NSSI in the empirical and clinical literature, consensus has not yet been reached about how to best conceptualize the behavior. Early research regarded NSSI as a symptom of Borderline Personality Disorder (BPD, Schaffer et al., 1982; Dulit et al., 1994); consistent with this perspective, the Diagnostic and Statistical Manual (DSM-IV-TR; American Psychiatric Association, 2000) classifies NSSI as a symptom of BPD. Others have conceptualized NSSI as a disorder of impulse control (Favazza and Rosenthal, 1993; Herpertz et al., 1995; Herpertz et al., 1997). More recently, researchers have argued that converging evidence supports conceptualizing NSSI as a disorder of emotion dysregulation (Chapman et al., 2006; Klonsky, 2007; Gratz and Roemer, 2008; Klonsky, 2009).

In addition to the conceptualizations described above, NSSI has also been viewed as an addictive behavior. Early work described a wide range of self-harm behaviors as addictive because they were both “coercive” and “relieving” (Tantam and Whittaker, 1992, p. 462). Faye (1995) presented a theoretical rationale for conceptualizing NSSI as an addictive behavior; specifically, she suggested that the increase in negative emotions prior to NSSI is analogous to the aversive withdrawal symptoms experienced by drug users. She further noted that self-injurers and drug users share similar ages of onset and similar rates of histories of childhood abuse. Other authors have investigated addictive aspects of NSSI in phenomenological studies, using case reports from clients with BPD (Karwautz et al., 1996), as well as semi-structured interview assessments of emotional pathways to cutting (Huband and Tantam, 2004). Recent work suggests that individuals who engage in NSSI often experience strong urges to self-injure (Washburn et al., 2010). Additionally, some findings indicate that endogenous opioids may be reduced among individuals who engage in NSSI, particularly those with comorbid Borderline Personality Disorder, suggesting that NSSI may be used by some to artificially stimulate the endogenous opioid system (Sher and Stanley, 2008; Bandelow et al., 2010; Stanley et al., 2010; but for evidence contradicting the opioid hypothesis of NSSI also see Russ et al., 1994; Lee and Stanley, 2009).

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Despite the conceptual and qualitative accounts described above, only one study to date has investigated an addictions model of NSSI empirically (Nixon et al., 2002). Nixon and colleagues examined addictive qualities of NSSI in adolescent psychiatric patients who had engaged in repetitive NSSI in the previous six months. The study included a self-report measure of addictive aspects of NSSI based on the DSM-IV criteria for substance dependence. The measure assessed seven addictive criteria, such as loss of control over NSSI, increasing tolerance, and increased tension if NSSI was not performed. Examples of items include “SI [self-injury] continues despite recognizing it as harmful,” “frequency and/or intensity has increased to achieve the same effect,” and “tension level reoccurs if discontinue SI” (p. 1338). Consistent with an addiction model of NSSI, the authors found that all participants reported having urges to self-injure after a stressful event, and 79% reported almost daily urges to self-harm. Further, 98% of participants endorsed at least three of the addictive criteria, and 81% endorsed more than five criteria.

Whereas Nixon et al. (2002) provide intriguing evidence that NSSI exhibits features of addiction, we suggest an important manner in which NSSI and addictive behaviors may differ: the relative roles of positive and negative reinforcement in perpetuating the two behaviors. In substance disorders, positive reinforcement plays an important role in the motivation and perpetuation of substance use. That is, drugs produce positive emotions, and addiction results in part from the desire to continually produce these pleasurable experiences (Stewart et al., 1984). Recent neurobiological work indicates that drug addiction is due in part to the positive reinforcement associated with increasing extracellular dopamine levels in the brain (Kufahl et al., 2005; Ross and Peselow, 2009). Of course, negative reinforcement also plays a significant role in drug addiction; for example, substances may be used to alleviate negative mood states or to prevent negative physical or psychological experiences, such as withdrawal (Wise and Bozarth, 1987; McCarthy et al., 2010). However, it is the clear and important role of positive reinforcement that may distinguish addictive behaviors like substance use from NSSI, in that while both positive and negative reinforcement sustain substance use, only negative reinforcement perpetuates NSSI.

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In contrast to the literature on substance use, extensive research suggests that NSSI is primarily maintained by negative reinforcement, and specifically the reduction of aversive negative emotional states (for reviews see Chapman et al., 2006; Klonsky, 2007; Nock, 2010). A study of adolescent self-injurers found that the most common emotions before NSSI were negative (overwhelmed, sad, hurt emotionally, frustrated), while the least common were positive (relieved, euphoric, satisfied) (Klonsky, 2009). The same study found that the largest change in emotions from before to after engaging in NSSI involved states indicating the removal of negative emotions, such as relief, which was reported to increase by more than two standard deviations from before to after engaging in NSSI. In contrast, increases from before to after NSSI were negligible for positive emotional states such as euphoria and excitement. It is noteworthy that even in Nixon et al. (2002), which describes important similarities between NSSI and addictive behaviors, the most common motivation for NSSI reported by participants was “to cope with feelings of depression.” We could find only one study that has directly compared the role of negative emotions for NSSI and substance use (Coid, 1993). In a sample of female inpatients with BPD, researchers found that NSSI was described as exclusively dependent on negative mood for 64% of participants compared to only 19% for substance abuse. The primary role in NSSI of negative reinforcement – of reducing aversive emotions – is highlighted in many other studies as well (Kemperman et al., 1997; Briere and Gil, 1998; Nock and Prinstein, 2004; Laye-Gindhu and Schonert-Reichl, 2005; Klonsky and Glenn, 2009).

Given evidence for both important similarities and differences between NSSI and addictive behaviors, the present study sought to compare NSSI and substance use on a key dimension of addiction relating to the nature of reinforcement: craving. The DSM-IV-TR (American Psychiatric Association, 2000) defines craving as “a strong, subjective drive to use the substance” (p. 192). While specific definitions and models of craving differ by theoretical orientation, a recent review by Skinner and Aubin (2010) suggested that craving can be defined as “a desire of any intensity to consume a substance…. Craving generally sets in motion a strong motivation, akin to an obsession, to do what is thought necessary to relieve it” (p. 620). Craving plays a pivotal role in perpetuating addictive use of substances (Gawin and Kleber, 1986; Roberts and Koob, 1997).

Understanding the extent to which craving occurs in NSSI and manifests similarly to craving in substance use would help determine the relevance of addictions models for NSSI. Although our study design allows for the possibility that craving will manifest similarly in NSSI and substance use, we hypothesize an important difference. We expect craving in NSSI versus substance use to reflect the differing roles that positive and negative reinforcement play in the perpetuation of the two behaviors. In short, we expect that substances will be craved across a variety of situations and contexts, consistent with the roles of both positive and negative reinforcement in substance use (Grunberg, 1994; Koob and Le Moal, 2001). In contrast, we expect NSSI to be craved almost exclusively in the context of negative emotions, consistent with the emotion-regulation and negative reinforcement models of NSSI (Chapman et al., 2006; Klonsky, 2007). In order to assess these issues, we developed a psychometrically sound craving measure suitable for use with both NSSI and substance use, and administered the measure to adolescent psychiatric patients with histories of NSSI, substance use, or both.

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