Characteristics and associated factors of non-suicidal self-injury among Italian young people: a survey through a thematic website.

BACKGROUND AND AIMS: The aim of this study is to examine the characteristics of non-suicidal self-injury (NSSI) in a group of young Italians who self-injure. In examining the characteristics, specific attention was given to the feelings and personal experiences associated with episodes of NSSI.
METHODS: The research involved 362 young people (332 females and 30 males) who completed an online survey hosted on a website specifically geared to supporting young people who self-injure. This methodology enabled involving a diverse population of young people who self-injure, thus going beyond specific groups or clinical samples.
RESULTS: Results show that the majority of respondents start injuring themselves between the ages of 12 and 16 years (72.38%, n = 262). Cutting was the most common self-injuring method (81.77%, n = 297). The 79.83% (n = 289) of respondents had not sought professional help for their wounds, preferring to care for their wounds on their own. More than half of the respondents (56.91%, n = 206) claimed to have experienced anxiety-spectrum disorders and almost half of the respondents (41.71%, n = 151) claimed to have experienced some type of eating disorder. DISCUSSION AND
CONCLUSIONS: Many similarities have been found between this study and the literature, thus strengthening the hypothesis that NSSI is becoming a universal issue with similar characteristics across countries.

Introduction

In these challenging times in which young people feel increasingly worried about their future, non-suicidal self-injury is becoming a growing issue among the youth in Western society (Cerutti, Manca, Presaghi & Gratz, 2011; Hawton, Rodham, Evans & Harriss, 2009; Lloyd-Richardson, Perrine, Dierker & Kelley, 2007; Whitlock, Eckenrode & Silverman, 2006).

Non-suicidal self-injury (NSSI) has been defined by the International Society for the Study of Self-Injury as “the deliberate, self-inflicted destruction of body tissue without suicidal intent and for purposes not socially sanctioned. It is also sometimes referred to as self-injurious behaviour, non-suicidal self-directed violence, self-harm, or deliberate self-harm (although some of these terms, such as self-harm, do not differentiate non-suicidal from suicidal intent)” (ISSS, 2007).

Because of methodological challenges in reaching people who self-injure as they seldom come to the attention of care services, it is difficult to know the scale of the issue among young people. However, a study conducted in Australia between 1992 and 2008 observed that over 8% of the sample (149 out of 1802) reported self-injuring from the age of 14 to 19 (Moran et al., 2012). In 2011 in the UK, Accident and Emergency services reported intentional self-injury related visits for 0- to 18-year-olds increased by 14% from 2008 (NHS, 2011). NSSI is an issue which is rapidly escalating in Italy too, although it is difficult to provide accurate numbers. A research undertaken among 578 students recruited in the Faculties of Psychology and Educational Sciences at the Universities of Palermo and Milan showed 20% of respondents self-injured at least once in their life (Sarno, Madeddu & Gratz, 2010).

On average, people start self-injuring between 14 and 24 years old, with a peak between the ages of 12/14 and 18/19 (Kerr, Muehlenkamp & Turner, 2010). Therefore, NSSI is an issue which mainly affects teenagers (Favazza & Conterio, 1988; Ross & Heath, 2002; Walsh & Rosen, 1988); some research suggests that, once young people mature, NSSI tends to disappear to be replaced by safer ways to cope with distress (Walsh & Rosen, 1988).

The group which is most at risk of self-injuring is single middle class females (Darche, 1990; Favazza & Conterio, 1988). There are contrasting hypotheses as to whether or not gender affects self-injuring behavior. Some authors observe that females are more likely to self-injure than males (Briere & Gil, 1998). Other authors reject this thesis (Cerutti et al., 2011; Sarno et al., 2010), arguing that females are more likely to disclose their NSSI than males, and therefore to be captured by national statistics (Rodham, Hawton & Evans, 2004).

The most common method of NSSI is cutting, followed by scratching, banging and pinning (Nock & Prinstein, 2005). The areas where wounds are most likely to be located are arms and wrists (Favazza, 1996). The majority of people only self-injure during difficult times and not chronically (Nock, Joiner, Gordon, Lloyd-Richardson & Prinstein, 2006; Whitlock et al., 2006).

Even though there is a growing body of studies on NSSI, they mainly concentrate on English speaking countries. Furthermore, most of the research has focused on the phenomenology and functional aspects of NSSI, and not on emotional and personal circumstances.

The aim of this study is to examine the characteristics of non-suicidal self-injury and associated factors in a sample of young Italians who self-injure and who were recruited through a thematic Internet website (www.SIBRIC.it). In examining these factors, specific attention was given to the feelings and personal experiences associated with NSSI.

Methods

Sample and procedure

A total of 362 young people who self-injure participated in the study (12 to 30 years old), filling in the online questionnaire and giving their consent to the processing of data between December 2007 and April 2011. The questionnaire is available on an Italian website specifically geared to supporting young people who self-injure. Through the website it was possible to participate in this research, find information about NSSI and get on-line support. SIBRIC is indexed on google with different keywords, and can be reached via a number of partner sites, therefore it is easily accessible to those interested in the topic of NSSI. The choice of a web-site as a place for research arises from the need to reach a large and heterogeneous group of self-injurers, and collect data on the characteristics associated with their practice of NSSI. In fact, today, for many young people, the Internet is the ideal medium for self-expression as it enables anonymity, which is important when faced with difficult or sensitive issues such as mental health and NSSI. Furthermore, it seems that the Internet has a certain relevance for young people who feel marginalized because it provides a low risk “venue” for finding others who share their perceived or real differences, and for exchanging information that is difficult to convey in person, or when using one’s real identity (McKenna & Green, 2002).

Participants were self-selected and self-declared self-injurers, therefore the results obtained depend on the respondent’s subjective evaluation of their experience and behavior, which cannot be verified (therefore, the possibility for deception or simulation exists).

Non-Italian individuals between 12 and 30 years were excluded from the group of participants as were those who engaged in indirect forms of self-harm (risk taking, dangerous driving, etc.) or other kinds of behavior not included in the definition of NSSI.

Measures

The survey consists of five demographic questions, one question asking about the age when the first wound was inflicted and 15 other open-ended questions. The development of the survey questions was informed by a comprehensive literature (Briere & Gil, 1998; Favazza, 1996; Favazza & Rosenthal, 1993; Muehlenkamp, 2005; Murray, Warm & Fox, 2005; Nock & Prinstein, 2005; Suyemoto, 1998; Yates, 2004) and reviewed by a team of independent experts in the field.

The coding of answers involved the identification of specific categories for each response, and their grouping according to similar responses by topic and/or value. The coding framework was cross-checked by two researchers, individually, to increase objectivity and reliability. However, due to the complexity of the answers, not all the data were coded into categories.

Here below is a list of the areas explored in the questionnaire:

The situation and setting of the first episode of NSSI

Frequency of NSSI and methods used

Perception of pain

Emotions felt before, during and immediately after the episode of NSSI

Preparation rituals

Substance misuse

NSSI in front of other people

Strategies to hide wounds

Talking to somebody about NSSI

Accessing medical and professional help

Use of pharmacological drugs and hospitalisation

Influence of NSSI on quality of life

NSSI and other mental disorders

Suicidal thoughts

Strengths of the methodology

The current literature presents two main methodological limitations. The first relates to sampling constraints. It is extremely hard to access people who self-injure, since most episodes never come to the attention of care services. Furthermore, most of the available studies are focused on rather homogeneous groups of respondents – i.e. young people who go to hospital as a result of their wounds, or students at colleges and universities.

The second limitation is the difficulty of getting people to talk honestly about their NSSI and their ability to translate their emotions into words.

By recruiting participants through a support website dedicated to NSSI, this research addressed these challenges. Firstly, the online questionnaire reached young people who self-injure but who may not have come to the attention of clinical services. Furthermore, the questionnaire allowed accessing a diverse population, beyond specific social groups or clinical samples.

Secondly, because of the relationship of trust built within the website and the benefit of anonymity, respondents were more likely to be honest and articulate their feelings and experiences. Furthermore, the choice of open-ended questions ensured answers were not lead by pre-determined categories and were able to capture young peoples’ emotions in a broader sense, as well as more details on the personal circumstances of their NSSI.

Ethics

The study procedures were carried out in accordance with the Declaration of Helsinki. Palermo University Psychology Department approved the study. All subjects were informed about the study and they all provided informed consent.

The objectives of the survey were clearly stated at the outset and the participants were informed of the right to withdraw at any time from the research.

Due to the sensitivity of the subject, careful precautions were taken to guarantee the safety and well-being of the young people who took part in the research. Firstly, the survey was completely anonymous, therefore it is impossible to trace the identity of participants. Secondly, to ensure the well-being of participants, questions which could have triggered negative reactions (for example relating to child abuse and maltreatment) were omitted. Finally, participants were given the contact details of trained psychologists working for SIBRIC.it who were available to give support at any time.

Given that identifiable information on participants was not acquired, and often parents are unaware of NSSI practice, it was considered inappropriate to ask for parental consent in the case of minors. Moreover, it was considered contrary to the best interests of the young person as well as capable of making matters worse.

Results

Participants were between 12 and 30 years old, with an average age of 19.39 (SD = 4.05; males 19.97 and females = 19.34, Figure 1). Of the 362 respondents, 332 (91.71%) were females and 30 (8.29%) males.

Figure 1.

Frequency distribution of ages of subjects (n = 362)

All the respondents lived in Italy, and the largest proportion (47.24%, n = 171) in Northern Italy, with a significant number from the region of Lombardy (18.23%, n = 66). One in five of the remaining respondents lived in Southern (20.99%, n = 76) and Central Italy (19.06%, n = 69).

The majority of over 18-year-old respondents (91.38%, n = 159 of the 174 respondents in this age bracket) had attained a high school diploma. A smaller proportion of them went to university; in fact, only 40.80% (n = 71) of over 18-year-olds (n = 71 of 174 respondents in this age bracket) stated they were either attending university or had attained a university diploma.

Participants were asked to describe a range of behavior or experiences that the literature associates with non-suicidal self-injury.

Characteristics of NSSI

Age of the first wound

Findings show respondents were more likely to start harming themselves between the ages of 13 and 16 (59.94%, n = 217, Figure 2), with an average age of 14.42 (males = 16.27 and females = 14.25).

Figure 2.

Distribution of first wound ages (n = 362)

However, after the age of 17, the risk of NSSI progressively decreased, as shown by the fact that only 3.31 % (n = 12) of respondents started self-injuring after the age of 20.

How young people self-injure

The most common method of NSSI was cutting, used by 81.77% of respondents (n = 297, Table 1). The tools employed were reported to be cutters, razor blades, scissors, knives, pencil sharpeners, pieces of glass. 16.85% of respondents (n = 61) scratched themselves with paper clips, needles or by using their own nails; 13.81% (n = 50) burnt themselves with cigarettes, hot objects or lighters; 9.94% (n = 36) hit themselves with different heavy objects.

Table 1.

How young people self-injure

Methods used	Subjects	%
Cutting	297	81.77
Scratching	61	16.85
Burning	50	13.81
Hitting himself	36	9.94
Self-biting	17	4.70
Picking at wounds	11	3.04
Scraping skin to draw blood	8	2.21
Punching walls	7	1.93
Pulling hair	4	1.10
Banging their head against the wall	4	1.10
Skin picking	3	0.83
Self-poisoning	3	0.83
Inserting objects into the skin or under fingernails	2	0.55
Biting nails until the blood	2	0.55
Strangulation/suffocation	2	0.55
Drawing blood from the veins	2	0.55
Tear off pieces of skin	1	0.28
Pinching	1	0.28
TOTAL (n = 362 Self-Injurers)

Other less frequent methods of NSSI were self-biting (4.70%, n = 17) and picking at wounds (3.04%, n = 11). The remaining 11.05% of the respondents (n = 40) used methods such as punching walls, pulling hair, banging their head against the wall, skin picking, self-poisoning, etc.

The majority of respondents used one single method to hurt themselves (56.35%, n = 204), which was generally cutting. 36.74% of respondents (n = 133) used multiple methods, generally cutting and burning (12.43%, n = 45), cutting and scratching (11.60%, n = 42) and cutting and banging (8.84%, n = 32).

Perception of pain

The biggest proportion of respondents said they could feel pain while hurting themselves (28.18%, n = 102); 17.96% (n = 65) reported they could feel a little pain; 17.96% (n = 65) stated they felt no pain; 11.33% of respondents (n = 41) stated they only sometimes felt pain. Specifically 8.84% of them (n = 32) said they felt pain only after having self-injured and a small percentage of respondents (2.21%, n = 8) said they could only feel pain the first times they were hurting themselves.

Interestingly, 5.80% of respondents (n = 37) said they experienced a feeling of pleasure when they self-injured.

How frequently young people self-injure

One in five respondents (19.89%, n = 72) said that the frequency with which they harmed themselves depended on the difficulties of life circumstances; they alternated “critical periods” when they self-injured very often with periods when they did not hurt themselves at all.

46.13% of respondents (n = 167) self-injured more regularly: 12.15% (n = 44) daily, 17.68% (n = 64) weekly, 16.30% (n = 59) at least once a month. Only 3.59% of respondents (n = 13) said they had not self-injured in previous months.

NSSI in front of other people

72.10% of respondents (n = 261) said they had never harmed themselves in front of others. The remaining 27.35% of respondents (n = 99) said they hurt themselves in front of others. Specifically, 3.04% (n = 11) in front of their partner; 2.76% (n = 10) in front of classmates; 1.93% (n = 7) in front of parents or family; 1.93% (n = 7) in front of friends; 0.83% (n = 3) in front of another person experiencing NSSI; 16.85% (n = 61) did not specify.

Strategy used to hide wounds

The majority of respondents shared concerns about not being able to hide their wounds properly (86.46%, n = 313). They hid their scars mainly by covering them with clothes or accessories, such as long sleeved shirts, watches, bracelets, wristbands, leg-warmers, etc. Some of the respondents specifically mentioned that they did not hurt themselves over the summer, since it is harder to hide scars.

Location of wounds

Wounds were more likely to be concentrated on arms (67.13%, n = 243), wrists (23.20%, n = 84), legs (21.55%, n = 78) and hands/fingers (18.78%, n = 68). All statistics are presented in Table 2.

Table 2.

Location of wounds

Body areas	Subjects %	%
Arms	243	67.13
Wrists	84	23.20
Legs	78	21.55
Hands/Fingers	68	18.78
Thighs	24	6.63
Shoulders/Back	24	6.63
Ankles	22	6.08
Abdomen/Stomach	22	6.08
Breast/Chest	19	5.25
Hips/Ass	15	4.14
Head	12	3.31
Feet	9	2.49
Face	7	1.93
Groin	5	1.38
Knees	4	1.10
Elbow	4	1.10
TOTAL (n = 362 Self-Injurers)

Why people self-injure the first time?

Respondents were asked to describe the situation in which they had harmed themselves the first time. The biggest proportion of respondents (23.20%, n = 84) said the first time they had self-injured because of relationship problems with family, friends or partner (Table 3).

Table 3.

Why people self-injure the first time?

Why/Reason	Subjects	%
Relationship problems (with family, friends or partner)	84	23.20
Loneliness	37	10.22
Difficulties to manage emotions	35	9.67
Guilt/Self-punishment	29	8.01
Inadequacy/Sense of inferiority	17	4.70
Traumatic event (bereavement, separation, etc.)	16	4.42
Problems with school	15	4.14
Curiosity/Game/Emulation	13	3.59
Violence/Abuse	11	3.04
Stress	11	3.04
Conflicts between parents	10	2.76
Attracting attention	9	2.49
Sense of unreality/vacuum	7	1.93
Disappointment	7	1.93
Depression	2	0.55
Homosexuality/Bisexuality	1	0.28
Don’t know/Not specified	79	21.82
Total (n = 362 Self-Injurers)

10.22% of respondents (n = 37) said the trigger for their first episode of NSSI was loneliness; 9.67% (n = 35) said it was difficulties in managing their emotions; 8.01% (n = 29) said it was the need to punish themselves.

Less frequent issues that led respondents to self-injure the first time were feelings of being inadequate and worthless (4.70%, n = 17), traumatic events such as death or separation from a close person (4.42%, n = 16), problems with school (4.14%, n = 15), curiosity and wish to emulate others self-injuring (3.59%, n = 13) and abuse (3.04%, n = 11).

Feelings and emotions associated with NSSI

Respondents were asked how they felt, before, during and after self-injuring. Unfortunately, due to the complexity of the answers obtained, it was not possible to encode data into categories as for the other answers. However, by analyzing the content of the answers, some frequent responses were isolated based on the feelings characterizing the moment immediately preceding the episode of NSSI.

Some respondents said they felt overwhelmed by negative feelings that they were unable to express (such as anger, anxiety); in these cases NSSI helped them release the tension and calm down. Other respondents reported feeling “empty” and numb, far from reality and from their own body; in these cases people harmed themselves to be able to feel something, to get back into contact with their body. Other respondents stated that, just before injuring themselves, they felt oppressed by a sense of guilt, and in these cases NSSI played the role of punishment.

Respondents were also asked to describe the emotions they felt while hurting themselves. In this case, mainly, the majority of respondents said that while hurting themselves their painful emotions froze, they entered a trance-like state and could not feel anything. A few respondents mentioned the fact that, by focusing on the physical pain, they were able to feel alive again.

Finally, in relation to the feelings emerging straight after self-injuring, they said that they felt a sense of relief, of satisfaction, of being relaxed. Some respondents recognized that the achievement of this “catharsis” could create addiction. It is important to address that some other respondents felt guilty while hurting themselves, guilty because they had relapsed.

Effects of NSSI on the quality of life

Respondents were asked whether NSSI had negative effects on their quality of life. Interestingly, 24.86% of respondents (n = 90) answered negatively.

Among those 70.72% of respondents (n = 256) who admitted NSSI had an influence on them, the majority recognized NSSI had negative effects on their life. What is interesting is that in most cases this negative effect was mainly related to the wounds; in fact, these respondents said their fear of being discovered caused them social difficulties, since they became diffident, irritable and uncomfortable with other people; ultimately they isolated themselves for fear of being judged. Only a few respondents (3.04%, n = 11) recognized that the negative consequences of their NSSI depended on the reasons which had triggered them to hurt themselves, as opposed to its physical consequence. Finally, a minority of respondents (3.87%, n = 14) stated that harming themselves had helped them cope with day-to-day difficulties.

Factors associated with NSSI

Misuse of substances

Half of respondents (51.10%, n = 185) said they had never abused alcohol or other substances. Of the other half, 20.99% of respondents (n = 76) had misused more than one substance. Specifically, 40.61% (n = 147) stated they had abused alcohol, 21.55% (n = 78) light drugs, only 4.97% (n = 18) hard drugs, 1.10% (n = 4) hallucinogen and 0.83% (n = 3) volatile substances.

NSSI and eating disorders

Almost the half of respondents (41.71%, n = 151) claimed to have experienced some type of eating disorders. Specifically, 10.22% (n = 37) experienced bulimia, 6.08% (n = 22) anorexia, 6.08% (n = 22) bulimia and anorexia, 3.87% (n = 14) occasional binge eating and 1.66% (n = 6) Binge Eating Disorder. The remaining 13.81% of the respondents (n = 50) stated that they had experienced an eating disorder without specifying the type.

NSSI and anxiety

More than half of the respondents (56.91%, n = 206) claimed to have experienced anxiety-spectrum disorders; specifically, 36.46% (n = 132) suffered anxiety disorders, 16.85% (n = 61) panic attacks and 3.59% (n = 13) social phobia.

NSSI and suicide feelings

The majority of respondents (77.07%, n = 279) claimed having had suicidal thoughts, but only one in 10 (10.22%, n = 37) had tried to end their life. Interestingly, respondents who had attempted suicide tried different methods than the ones they used to hurt themselves, the most common being drug overdose.

Help seeking

Disclosing

As mentioned above, the majority of respondents shared concerns about not being able to hide their wounds (86.46%, n = 313), supporting the thesis that describes NSSI as a “secretive issue” (Yates, 2004). However, despite the secretive nature of NSSI, the majority of respondents had spoken face-to-face to somebody about their problem (80.94%, n = 293). This can be explained by the fact that sometimes people are overwhelmed by what is happening in their life and therefore feel the need to share their emotional pain with somebody else (Conterio & Lader, 1998; Walsh, 2005). Those people who had talked to somebody about their NSSI were more likely to have gone to a person close to them. Specifically, 29.56% of respondents (n = 107) had opened up about their issue with friends or classmates; 15.19% (n = 55) with their partner; 7.73% (n = 28) with their family. Interestingly, only one in four respondents (24.86%, n = 90) had talked about their NSSI with more than one person. Specifically, 15.47% (n = 56) shared their issue with more than one friend and 4.97% with a friend and partner (n = 18). Interestingly, a small proportion of respondents had spoken to another person who self-injured (4.44%, n = 16).

Medical treatments

Data shows that the majority of respondents had not sought professional help for their wounds (79.83%, n = 289), preferring to care for their wounds on their own. The remaining 10.22% of respondents (n = 37) had gone to a doctor, but only in extreme cases when the wounds were deep. Furthermore, 1.66% of respondents (n = 6) had gone to a dermatologist to find solutions to hide the wounds.

Hospitalization

Only 3.87% of respondents (n = 14) had been hospitalized because of their wounds; 1.38% (n = 5) reported having been hospitalized because of an overdose of psychopharmacological drugs, and not because of their wounds.

Use of psychopharmacological drugs

The majority of respondents (72.93%, n = 264) had never taken psycho-pharmacological drugs to help them with their NSSI. Some respondents explained that taking psychopharmacological drugs would mean admitting that they were “ill”; other respondents did not like the idea of becoming addicted to medication; others did not want to take psychopharmacological drugs because they did not want to lose control over their emotions and body.

27.07% of respondents (n = 98) had taken psychopharmacological drugs, and 10.22% (n = 37) had taken more than one type. Specifically, 17.96% of respondents (n = 65) said they had taken anxiolytics; 13.81% (n = 50) antidepressants; 3.31% (n = 12) mood stabilizers and 2.76% (n = 10) antipsychotics.

Discussion

In interpreting the results, it is necessary to take into consideration that the sample is based on a group of young people recruited on the Internet, therefore data and conclusions may not be representative of the entire population of self-injurers.

The majority of participants were women, about 17 years old, from Northern Italy and have been self-injuring for three years since the age of 14. Like most other young people who self-injure, when they hurt themselves they mainly cut, but this is not always the case, and sometimes they try other methods such as scratching, banging, pinning; the wounds are concentrated in their arms and wrists. Most of the respondents say that in some periods they self-injure every week, while in other periods they do so less frequently – this seems to depend on what is going on in their life at that time. Many of them convey that they have other issues they are struggling with: they suffer from eating disorders and sometimes have panic attacks. From time to time they drink too much, but not more often than friends. Many of the respondents say they do not take drugs regularly. On a few occasions they have thought about ending their life, but they have never attempted suicide. From the point of view of those interviewed, suicide and NSSI are two distinct kinds of behavior: NSSI is a way of coping with difficulties rather than giving up on life; it fulfils a crucial function of self-help and is a mechanism to prevent suicide (Favazza, 1996; Suyemoto, 1998).

Some claim to be trapped in a spiral of tension/relief, tension/relief which is hard to break, and affects general well-being. The majority of those interviewed recognize that this loop has negative effects on their lives. What is interesting is that they are mainly concerned about scars, and not NSSI itself, probably because they are constantly worried that other people will see their wounds and discover their problem. They try to hide scars the best they can, but are still wary of social situations and are uncomfortable around other people.

Although the findings suggest NSSI is an issue that mainly affects teenagers (Kerr et al., 2010; Whitlock et al., 2006), data show a reduced risk of NSSI among younger respondents, in fact 19.89% of them started hurting themselves between the ages of 9 and 12.

Consistent with prior studies, 72.10% of respondents said they had never harmed themselves in front of others, corroborating the hypothesis which states that NSSI is a hidden issue and not aimed at attention seeking (Conterio & Lader, 1998; Favazza, 1996).

Gender differences were observed in the examined group. Female respondents were more likely to start self-injuring two years before male respondents (the average starting age for females was 14.25 and for males 16.27). This can be explained by the fact that females and males have different experiences while growing up, with boys entering puberty and facing the challenges of adolescence typically later than girls.

The areas of the body most often affected were arms, wrists and legs, and hands/fingers. Perhaps because they are easier to cover, hence the wounds can be hidden more easily (Murray et al., 2005). A big problem for the majority of respondents seems to be hiding scars. They hide their scars mainly by covering them with clothes or accessories, such as long sleeve shirts, watches, bracelets, wristbands, leg-warmers, etc. Some of the respondents specifically mentioned that they did not hurt themselves over the summer, since it is harder to hide scars. This finding is corroborated by the literature (Murray et al., 2005).

When they were discovered, respondents said they made up justifications for their wounds, such as being scratched or attacked by animals (specifically cats); having had an accident; suffering from some form of skin allergy or rash.

In line with other studies, the majority of respondents said that they began to self-injure because they had relationship problems with somebody close (Nock & Prinstein, 2005). Subsequently, self-injuring becomes a way to manage a whole range of negative feelings which seem to overwhelm them. Cutting helps them calm down, since they enter a trance-like state where everything freezes and they are finally free from mental pain. For them NSSI is an “emotional regulator”, a relief valve used to let out bad emotions and reinstate a state of calm. Therefore, NSSI takes on an impulsive connotation; it is automatic and is undertaken in moments of crisis (Castille et al., 2007; Favazza & Conterio, 1989).

In relation to abuse of substances, compared with national data the findings suggest that the percentage of abuse of substances in the group of self-injurers interviewed is not higher than the general population (Serpelloni, Zermiani, Candio & Zusi, 2008).

Considering that an average of 20.16% of Italian females and 3.26% of Italian males suffer eating disorders (Miotto, De Coppia, Frezza & Preti, 2003), the above findings suggest there may be a correlation between NSSI and eating disorders (Favazza, DeRosear & Conterio, 1989; Muehlenkamp, 2005).

As well as eating disorders, anxiety-spectrum disorders also probably have a correlation with NSSI, considering the high level of anxiety symptoms reported (Briere & Gil, 1998; Herpertz, 1995; Klonsky, 2007; Muehlenkamp, 2005).

The relatively low percentage of respondents who said they had tried to end their lives along with the fact that there are different methods to self-injure and attempt suicide suggests that, in line with other studies, these are distinct kinds of behavior (Favazza & Rosenthal, 1993; Stanley, Gameroff, Michalsen & Mann, 2001). Another finding that corroborates this hypothesis is the fact that only a minority of respondents needed medical care for their wounds, suggesting they knew how far to go when hurting themselves.

Few young people said they had talked to another person about their difficulties, and those who did, were more likely to have gone to a person close to them. These data corroborate the thesis according to which NSSI has a secretive nature: young people struggling with this issue prefer to confide only in one person when they cannot keep the problem to themselves. A further confirmation is the tendency that emerged in our sample of avoiding professional help, so much so that some respondents stated that they took medication without prescription by a professional (general doctor and psychiatric), reinforcing the hypothesis that people who self-injure tend to avoid contact with professionals and doctors as much as they can (Hawton et al., 2009; Sarno et al., 2010; Whitlock et al., 2006). They say that they prefer to take care of their wounds on their own. In fact, they often have all that is necessary for self-medication and rarely inflict cuts so deep as to require the emergency room; many of them say they know when to stop self-injury without needing medical care. In line with what was just said, and with other studies, the results obtained vis-à-vis “hospitalization” reinforce the hypothesis that most people who self-injure never come to medical attention (De Leo & Heller, 2004; Lloyd-Richardson et al., 2007). A possible explanation is that NSSI may generate shame and lead people experiencing this issue to become isolated (Hawton et al., 2009; Whit-lock et al., 2006).

Limitations

There are some limitations to this research. Even though the sample is of a good size, it is affected by self-selection biases. The sample is skewed towards those people who self-injure and who have already taken steps towards looking for help and information about their issue. Furthermore, since the research is based on self-reporting and self-diagnosis, some respondents might have not been self-injuring according to the definition of the International Society for the Study of Self-Injury.

Moreover, this online methodology excludes those people who – due to poor education, low income or practical limitations to web access – do not access or use the Internet. Therefore, these results cannot be generalized for a larger NSSI population.

Finally, even though the choice of asking open-ended questions provided greater insights on behavior and emotions, it has drawbacks. For example, due to the sensitive and intricate nature of NSSI, it might have been difficult for respondents to translate how they felt into words. Furthermore, because of the complexity of the answers, it was not always possible to code and quantify them. Moreover, the categorization of the answers is subject to a certain degree of subjectivity – even though the coding framework was checked for reliability.

Finally, the cross-sectional nature of this study, albeit a good way to study multiple characteristics, has more limited implications than a longitudinal one.

Conclusions

This study presents data collected through an Italian thematic website on self-injury, which has recently become a reference point for young people that engage in NSSI. The results highlight the characteristics of NSSI and other associated factors, in a group of young people who filled out the online questionnaire.

Findings show that there are similarities in NSSI behavior between young people in Italy and young people in other countries; these data reinforce the assumption that NSSI is becoming a universal issue which crosses geographical barriers (YouthNet, Associazione Photofficine Onlus, UTRIP & Cyberhus, 2012).

Although it is not possible to extend the characteristics of this group to all self-injurers, a specific picture emerges from this research.

Future research should focus not only on a self-selected sample of people who self-injure, but should be representative of the whole young population in Italy; in fact, there are no national statistics on NSSI among young people in Italy.

Furthermore, future studies should focus on the origin of NSSI as opposed to its characteristics; this is in order for professionals to be able to prevent the issue. Likewise, there is a need for more research when it comes to help-seeking behavior.

Finally, it would be interesting to run more cross-country and comparative studies to learn from other countries’ experiences and identify the commonalities and differences across cultures.

Conflict of interests

The author declares no conflict of interests.