Untended Wounds: The Unexplored Problem of Non-Suicidal Self-Injury in Adults with ASD

Background: Non-suicidal self-injury (NSSI) involves deliberate injury to body tissue that is inflicted without suicidal intent and for purposes that are not socially sanctioned. Recent studies have examined the characteristics and predictors of NSSI in community and clinical samples, but there is no published research on NSSI in individuals with autism spectrum disorder (ASD). This is somewhat surprising given that many of the most salient predictors of NSSI, including depression and emotion dysregulation, have been widely reported among people with ASD. Given the focus on self-injury as a form of restricted, repetitive behavior in individuals with ASD, NSSI in the context of ASD may be overlooked by both researchers and clinicians.

Objectives: The purpose of this study was to examine NSSI methods, frequency, severity, functions, and initial motivations in adults with ASD. Our secondary aim was to compare NSSI characteristics across adults with ASD and history of NSSI and adults without ASD but with history of NSSI. In addition, we explored the degree to which depression symptoms and emotion regulation difficulties are associated with NSSI in adults with ASD.

Methods: This study involved a two-group, cross-sectional survey, with one survey for adults in the community with ASD (n = 42) and one survey for university students without ASD (n = 1252). The anonymous online survey included the Non-Suicidal Self-Injury Assessment Tool (NSSI-AT), the Severity Measure for Depression-Adult, and the Difficulties in Emotion Regulation Scale (DERS).

Results: In the ASD sample, 21 participants (50%) reported engaging in NSSI behavior. A gender-matched subsample of participants who endorsed NSSI was drawn from our university-based survey (n = 21) in order to compare individuals with and without ASD on NSSI characteristics. Of the 18 women with ASD, 13 (72.2%) reported NSSI, compared to only 8 of the 24 men with ASD (33.3%), χ²(1) = 6.22, p = .013. There were no statistically significant differences between the ASD and non-ASD groups on any of the NSSI-AT items. Within the ASD group, point-biserial correlations revealed that a history of NSSI was not significantly related to current depression (r = -.013, p = .936) or emotion dysregulation (r = .054, p = .734). Within the subset of individuals with ASD who endorsed a history of NSSI, more difficulty with emotion regulation was significantly related to Sensation Seeking functions of NSSI (r = .512, p = .018).

Conclusions: This descriptive study is one of the first investigations of NSSI in adults with ASD. Our preliminary findings suggest that NSSI is (1) phenomenologically distinct from core ASD symptoms and similar to NSSI as it is conceptualized in the non-ASD literature, (2) a common problem among adults with ASD, and (3) overlooked in the extant research, and likely overshadowed or misconstrued (e.g., as SIB, or core ASD symptoms) in clinical practice.