Self-Injury in Autism: Predictors, Perceptions, and Links to Suicidality
Self-injurious behaviours (SIB), such as cutting or burning, are closely related to mental ill-health and suicidality 1. One preliminary study (Maddox et al., 2017) suggests that autistic people without intellectual impairment, the group who are at highest risk of suicidality, are a high-risk group for self-injury, too. These individuals engage in SIB in a qualitatively different way than autistic people with intellectual impairment, a way that shares many features in common with non-autistic people. Unfortunately, despite the links between SIB and suicidality in the non-autistic population and the increased risk of both in autistic people, understanding of self-injury and its relation to suicidality in this subgroup of the spectrum remains very limited.
We attempted to expand on this previous work by a) corroborating the previous description of autistic SIB with a bigger sample; b) exploring predictive factors for self-injury, and factors predictive of self-injury for specific functional goals; c) qualitatively exploring how autistic people perceive their self-injury and what helps them control or overcome it; d) and, in a second follow-up study, exploring relationships between self-injury and suicide ideation or attempts.
One hundred and three (n = 103) autistic participants were recruited for this online study from the Cambridge Autism Research Database (CARD) and from advertising on social media. Participants completed the Non-Suicidal Self-Injury Assessment Tool (NSSI-AT5) and were classified as current, historic or non-self-harmers. In a theory-driven approach, a number of variables were of interest led by the literature on SIB in autistic and non-autistic people, and therefore participants completed measures of alexithymia, anxiety, depression, mentalizing, autistic traits, and sensory experiences. In a follow-up study we asked participants to complete the Suicide Behaviours Questionnaire-Revised.
Our data corroborated many of the features and reasons for SIB as described in Maddox et al., but multinomial regression furthermore revealed that alexithymia and sensory-sensitivity significantly predicted the self-injury status of participants. Alexithymia was the only variable to predict SIB for any of the functional roles delineated by the NSSI-AT, specifically predicting SIB engaged in for regulating high energy states (e.g. agitation, anger) and communicative purposes. An interesting dichotomy emerged in the qualitative data between those distressed by their SIB and those who viewed it methodically as a tool (for instance, “to achieve homeostasis”). However, whereas current and historic self-harmers were significantly more likely to endorse statements indicating suicide ideation and attempts, there was no relationship between the distress participants felt at self-harming and their responses to the suicidality questionnaire.
Our findings highlight certain features, such as alexithymia and sensory sensitivity, as particularly notable for clinicians who might have concerns about self-injury in their autistic patients. A relationship between SIB and suicide ideation and attempts exists regardless of how autistic people feel about their self-injury, corroborating the idea of self-injury as a ‘time-invariant’ risk factor or ‘gateway’ for suicidality’.