The Self-Harm Inventory (SHI): Development of a Scale for Identifying Self-Destructive Behaviors and Borderline Personality Disorder

The Self-Harm Inventory (SHI): Development of a Scale for Identifying Self-Destructive Behaviors and Borderline Personality Disorder Randy A. Sansone Wright State University School of Medicine Michael W. Wiederman Ball State University Lori A. Sansone Kettering Medical Center Physicians Incorporated Intentional self-harm behavior is an important clinical phenomenon that appears highly related to borderline personality disorder (BPD). Self-harm behavior in the context of borderline personality probably exists along a continuum from graphic, self-harm behavior to milder forms of selfsabotaging behavior that might be viewed as self-defeating. Relatively little attention has been paid to developing a self-report measure of intentional self-harm, particularly as a screening device for detecting BPD. In Study 1, an initial list of self-harm behaviors encountered in clinical practice was narrowed to those behaviors related to BPD in a sample comprised of adults from both a mental health and non mental health setting. All participants (N 221) underwent a semistructured diagnostic interview for BPD. Using a cut-off score of 5 on the resulting 22-item Self- Harm Inventory (SHI), 83.7% of research participants were correctly classified as having BPD or not. In Study 2, women (N 285) sampled from an outpatient medical setting completed the SHI and a widely used self-report measure of BPD. The SHI cut-off score resulted in correct classification of 87.9% of the individuals. In Study 3, using a sample of adults involuntarily hospitalized for psychiatric reasons (N 32), the SHI per- The authors wish to acknowledge the Laureate Research Foundation and Medical Care Associates of Tulsa. Correspondence concerning this article should be addressed to Randy A. Sansone, M.D., Sycamore Primary Care Center, 2115 Leiter Road, Miamisburg, OH 45342. JOURNAL OF CLINICAL PSYCHOLOGY, Vol. 54(7), 973 983 (1998) 1998 John Wiley & Sons, Inc. CCC 0021-9762/98/070973-11

974 Journal of Clinical Psychology, November 1998 formed at least as well as another self-report measure of BPD in diagnosing participants (the final diagnosis was based on a semistructured interview). The results are discussed with regard to potential advantages and utility of the SHI and need for further validation. 1998 John Wiley & Sons, Inc. J Clin Psychol 54: 973 983, 1998. Self-harm behavior is an important clinical phenomenon (Romans, Martin, Anderson, Herbison, & Mullen, 1995; Tantum & Whittaker, 1992; Van der Kolk, Perry, & Herman, 1991), and tendencies toward repetitive self-harm appear to comprise a distinct component of personality disturbance (Livesley, Jackson, & Schroeder, 1991). Clinicians have long associated repetitive and chronic self-harm behavior with borderline personality disorder (BPD). For example, Gunderson and Singer (1975) noted that impulsivity and self-harm behavior were the characteristics most commonly and consistently associated with BPD, and Mack (1975) referred to self-harm behavior as the behavioral specialty of individuals with BPD. Numerous other authors have highlighted patterns of self-harm behavior and their relation to BPD (e.g., Kernberg, Selzer, Koenigsberg, Carr, & Applebaum, 1989; Linehan, 1987; Schaffer, Carroll, & Abramowitz, 1982; Simeon et al., 1992; Walsh & Rosen, 1988). Finally, the association between self-destructive behavior and BPD is sufficiently consistent for many authors to recommend use of the existence of self-harm behaviors as a diagnostic sign to distinguish individuals with BPD from other severely disturbed individuals (Gunderson & Kolb, 1978; Gunderson, Kolb, & Austin, 1981; Perry & Klerman, 1980; Spitzer & Endicott, 1979). In addition to the clinical impressions and empirical studies associating self-harm behaviors and borderline personality, most, if not all, constructs for the disorder include some aspect of self-harm among the criteria for diagnosis. For example, in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV; American Psychiatric Association, 1994), two of nine criteria for borderline personality disorder involve self-harm behaviors. One is self-damaging impulsivity and the other is suicidal behavior, gestures, threats, or self-mutilation. Among the remaining nine DSM-IV personality disorders, there is only one other that has a related self-harm criterion; antisocial personality disorder includes physical fights or assaults as a diagnostic criterion. Among the empirical measures for BPD, self-harm behaviors are consistently noted as criteria for diagnosis. The Borderline Syndrome Index (BSI; Conte, Plutchik, Karasu, & Jerrett, 1980) includes 3 self-harm criteria out of 50 items, the Personality Disorder Examination (Loranger, 1988) 3 of 13 items, the Structured Clinical Interview for DSM- III-R Personality Disorders (SCID-II; Spitzer, Williams, Gibbon, & First, 1990) two of eight items, the Diagnostic Interview for Borderlines (DIB; Kolb & Gunderson, 1980) one of five items ( impulse action patterns ), the Borderline Personality Disorder Scale (BPD-Scale; Perry, 1982) two of nine items, and the Borderline Personality scale of the Personality Diagnostic Questionnaire-Revised (PDQ-R; Hyler & Rieder, 1987) 3 of 12 items. In summary, each measure incorporates some aspect of self-harm behavior. Based upon the potential clinical importance of self-harm behavior and the role of self-harm behavior in diagnosing BPD, it is surprising that relatively little empirical work has been conducted on measuring self-harm behavior. We are aware of only two measures of self-destructive behavior and both are subscales of broader psychiatric measures (Clark, 1993; Livesley, Jackson, & Schroeder, 1989). Typically, BPD is assessed through indi-

Self-Harm Inventory 975 vidual clinical interviews, which are labor intensive, or through self-report measures, which tend to be overinclusive (Patrick, Links, Van Reekum, & Mitton, 1995). The purpose of the current set of studies was to develop a brief, self-report inventory to measure history of intentional self-harm behavior and determine the relationship between selfharm behaviors and BPD. We believed that such an instrument, if developed, might aid both the clinician and researcher in measuring extent of self-harm experiences. We also believed that such a measure may prove to be a useful screening device for detecting BPD because in our clinical experience, many individuals with BPD manifest multiple forms of self-harm behavior. The purpose of Study 1 was to establish a self-harm inventory that would be predictive of BPD (diagnosed according to a semi-structured interview). Method STUDY 1: DEVELOPMENT OF THE SHI Participants. The overall sample (N 221) consisted of three subsamples. The first subsample consisted of obese participants in a study comparing the prevalence of borderline personality between obese and nonobese women in a primary care setting (Sansone, Sansone, & Fine, 1995). This subsample included 61 women who were consecutively seen in a health maintenance organization (HMO) by one female family physician. Participants who presented for nonemergent medical care were 50 pounds or more overweight, and their mean age was 34.7 years (SD 8.3 years). The second subsample consisted of participants in a study comparing the prevalence of borderline personality among individuals with eating disorders, substance abuse, or both (Sansone, Fine, & Nunn, 1994). This subsample was composed of three study cells: (a) individuals with an eating disorder (50 women and 2 men; 20 participants were diagnosed with bulimia nervosa, 22 with eating disorder NOS, and 10 with anorexia nervosa), (b) individuals with substance abuse disorders (22 women, 22 men), and (c) individuals with both an eating disorder and a substance abuse disorder (17 women). In addition to participants in these study cells, four additional women that were excluded in the previous published study because of incomplete data were included in this study. This subsample was solicited from a private free-standing psychiatric facility in Oklahoma through the eating disorder and substance abuse programs, both of which included inpatient, partial hospitalization and outpatient services. The majority of the subsample had been hospitalized at some point in their treatment for an eating disorder, substance abuse, or both. All participants met DSM-IV criteria for their respective diagnoses. The mean age of the subsample was 30.3 years (SD 9.8 years). The third and final subsample consisted of 43 women who were participating in a study comparing the prevalence of borderline personality in mothers of obese versus mothers of normal-weight adolescent girls. These participants whose mean age was 41.1 years (SD 3.3 years) were consecutively recruited during visits for nonemergent health care by a female family physician in an HMO setting. Measures. Borderline Personality Disorder. Each of the 221 participants were interviewed using the Diagnostic Interview for Borderlines (DIB; Kolb & Gunderson, 1980) and completed the Borderline Personality Disorder Scale of the Personality Diagnostic Questionnaire-Revised (PDQ-R; Hyler & Rieder, 1987). The Diagnostic Interview for Borderlines is a semistructured interview that is administered by a trained individual. It is divided into five sections, explores 29 symptoms of borderline personality including impulse action patterns, and provides structured questions as well as unstructured symp-

976 Journal of Clinical Psychology, November 1998 tom exploration. Each DIB takes approximately 45 60 minutes to administer. This measure has known reliability and validity and is noted for its strong psychometric properties (Armelius, Kullgren, & Renberg, 1985; Cornell, Silk, Ludolph, & Lohr, 1983; Frances, Clarkin, Gilmore, Hurt, & Brown, 1984; Gunderson et al., 1981; Hurt, Clarkin, Koenigsberg, Frances, & Nurnberg, 1986; Kroll et al., 1981; Loranger, Oldham, Russakoff, & Susman, 1984). The second measure for borderline personality disorder, the Borderline Personality Disorder scale of the PDQ-R (Hyler & Rieder, 1987), is an 18-item self-report survey based on the criteria for BPD as described in the DSM-III-R (American Psychiatric Association, 1987). Previous researchers have found this scale to be a useful screening measure for borderline personality symptomatology in both clinical (Dubro, Wetzler, & Kahn, 1988; Hyler et al., 1990) and nonclinical (Johnson & Bornstein, 1992) samples. Self-Harm Behaviors. All participants completed the pilot version Self-Harm Inventory (SHI), a 41-item self-report questionnaire that explores types of self-destructive behaviors in which respondents may have engaged. Individual items were developed from behaviors described in the literature and the clinical experience of the authors and their associated multidisciplinary treatment teams (i.e., the SHI was reviewed by multiple clinicians who offered suggestions for additional items). The list of SHI items was preceded by the statement, Have you ever on purpose, or intentionally.... Response options were yes or no. Items included a variety of self-destructive acts such as, overdosed, banged your head on purpose, driven recklessly on purpose, had accidents on purpose, and engaged in physically abusive relationships. A score on the SHI is the summation of endorsed self-harm behaviors (i.e., number of yes responses). At the end of the SHI, there is an area for respondents to write in any self-destructive behaviors that were not specifically addressed in the questionnaire. (A copy of the SHI is available from the authors.) Procedure. In their various settings, all participants completed the DIB, Borderline Personality Disorder scale of the PDQ-R, and the SHI onsite following the provision of written informed consent. The order of presentation of the interview and research booklet were counterbalanced. Results In creating the final version of the SHI, items were selected based upon their correlation with the total DIB score. For scale development, the DIB was selected as the comparison measure over the PDQ-R, which has been criticized for being overinclusive (Dubro et al., 1988; Hurt, Hyler, Frances, Clarkin, & Brent, 1984; Patrick et al., 1995). Those SHI items not correlated to the DIB, many of which were endorsed by very few respondents, were deleted, leaving 22 items. The proportion of respondents who endorsed each of the 22 remaining SHI items ranged from a low of 4.7% for the item burned yourself, to a high of 37.6% for the item abused alcohol. The distribution of scores (i.e., total number of self-harm endorsements) on the 22-item SHI are presented in Table 1 as a function of diagnostic group. As one would expect, scores on the 22-item SHI were highly correlated with scores on the DIB (r.76, N 221). The ability to predict a diagnosis of borderline personality (based on the DIB) using various cutoff scores on the SHI is presented in Table 2. Using a cutoff score of 5 on the SHI appears to best balance diagnostic sensitivity with false-identification of BPD.

Self-Harm Inventory 977 Table 1. Distribution of Self-Harm Inventory (SHI) Scores (N = 221) and Their Relationship to a Borderline Diagnosis According to the DIB SHI Score Borderline* n (%) Nonborderline* n (%) 0 0 (.0) 62 (36.9) 1 1 (1.9) 17 (10.1) 2 1 (1.9) 27 (16.1) 3 2 (3.8) 12 (7.1) 4 2 (3.8) 20 (11.9) 5 5 (9.4) 7 (4.2) 6 1 (1.9) 9 (5.4) 7 4 (7.5) 6 (3.6) 8 1 (1.9) 4 (2.4) 9 7 (13.2) 3 (1.8) 10 or greater 29 (54.7) 1 (.06) Total N 53 (100) 168 (100) Mean SHI Score (SD) 10.15(4.57) 2.30(2.51) *Based on Diagnostic Interview for Borderlines (DIB; Kolb & Gunderson, 1980). Scores on the PDQ-R and SHI were highly related (r.73, p.01). However, in comparing the SHI and the PDQ-R with regard to their ability to predict a DIB diagnosis of BPD, different levels of sensitivity were revealed between the two measures. Using the recommended cutoff score for the PDQ-R (Hyler et al., 1989), the PDQ-R accurately classified 88.7% of those with DIB-diagnosed BPD. This is the same rate of accuracy as the SHI (using a cutoff score of 5). In doing so, however, the PDQ-R only correctly classified 71.4% of individuals without a DIB diagnosis of borderline personality, for an overall accuracy of 75.6%. Using a cutoff score of 5 on each measure resulted in a Kappa of.47 for the PDQ-R versus a Kappa of.61 for the SHI. STUDY 2: INITIAL VALIDATION OF THE SHI Method Participants. For an initial validation study, two subsamples were obtained. Both consisted of women who were being seen for routine gynecological care by a female family Table 2. The Relationship Between Various SHI Scores and the Classification of Respondents as Having Borderline Personality Disorder (BPD) or Not According to the DIB SHI Score Correct Classification of Participants With BPD (According to the DIB) Correct Classification of Participants Without BPD (According to the DIB) Overall Accuracy 4 92.5% 70.2% 75.6% 5 88.7% 82.1% 83.7% 6 79.2% 86.3% 84.6% 7 77.4% 91.7% 88.2% Note. DIB = Diagnostic Interview for Borderlines (Kolb & Gunderson, 1980).

978 Journal of Clinical Psychology, November 1998 physician in a primary care HMO. The first subsample consisted of 133 women whose ages ranged from 17 to 52 years (M 33.11, SD 9.60). The second subsample consisted of 152 women who participated in a study exploring the presence and type(s) of trauma experienced during childhood (Sansone, Sansone, & Wiederman, 1995). Like the previous subsample, these participants were consecutively accessed during visits for routine gynecological care. Their ages ranged from 17 to 49 years (M 33.97, SD 9.0). Measures and Procedure. Measures included the Borderline Personality scale of the PDQ-R and the 22-item SHI, as described in Study 1. After providing written informed consent, all participants completed the measures onsite in a quiet examination room. Results Scores on the PDQ-R and the SHI were moderately correlated (r.57, p.01). It is widely recognized that using the usual cutoff score for the Borderline Personality scale of the PDQ-R results in relatively high rates of false positives (Dubro et al., 1988; Hurt et al., 1984), especially in nonclinical samples. Therefore, in the current study, we defined the BPD group as those individuals with a score of 6 or greater (n 38), using the guidelines proposed by Patrick et al. (1995), and the non-bpd group was defined as those respondents (n 176) with a score of 3 or less. Note that 71 women fell between these cutoff scores and were excluded from the analyses. The SHI scores of the resulting two groups are presented in Table 3. Using a cutoff score of 5 on the SHI, the overall accuracy of the SHI in classifying individuals was 87.9% (Kappa.51). Because this second sample of individuals did not represent a mental health sample, nor was the borderline personality diagnosis based upon an interview, we conducted a third study to validate the SHI as a screening measure for BPD within a more pathological group. Table 3. Scores on the Self-Harm Inventory (SHI) According to Participants Classification as Borderline (n = 38) or Nonborderline (n = 176) by the PDQ-R SHI Score Borderline Group n Nonborderline Group n 0 3 96 1 1 33 2 8 18 3 5 11 4 3 12 5 2 1 6 1 4 7 3 0 8 4 0 9 3 0 10 or greater 5 1 M 5.24 1.07 SD 3.77 1.63 Note. PDQ-R = Borderline Personality scale of the Personality Diagnostic Questionnaire-Revised (PDQ-R; Hyler & Rieder, 1987). Borderline designation is based on a score of 6 or greater and nonborderline designation is based on a score of 3 or less.

Self-Harm Inventory 979 Method STUDY 3: VALIDATION OF THE SHI AMONG PATHOLOGICAL INDIVIDUALS Participants. Participants consisted of 32 randomly sampled nonpsychotic adults (16 men, 16 women) who were involuntary hospitalized in a local psychiatry facility. Four had pending legal charges. Participants ranged in age from 18 to 63 years with a mean age of 36.2 years (SD 13.33). Measures. Each participant was interviewed by a fourth-year psychiatric resident and diagnosed according to the criteria for borderline personality disorder noted in DSM-IV (American Psychiatric Association, 1994). A checklist of criteria was reviewed by the resident with each participant. In addition to the DSM-IV-based semistructured interview, all participants completed the Borderline Personality scale of the PDQ-R as well as the SHI. Results Scores on the PDQ-R and the SHI were highly correlated (r.71, p.01). The SHI and PDQ-R scores are presented in Table 4 as a function of diagnostic group. Note that using the recommended cutoff score of 5, the PDQ-R correctly classified all of the individuals without BPD (no false positives). However, one third of those with BPD had a PDQ-R score below the clinical cutoff (false negatives). The overall accuracy of the PDQ-R in correctly classifying participants was 71.9% (Kappa.38). The SHI had a relatively low accuracy rate for classifying nonborderlines (60%) but had a relatively high accuracy rate for identifying individuals diagnosed as having BPD according to the DSM-IV-based interview (81.5%). The overall accuracy of the SHI in correctly classifying the research participants was 78.1% (Kappa.33). Table 4. Scores on the Self-Harm Inventory (SHI) and the Personality Diagnostic Questionnaire-Revised (PDQ-R) According to Participants Diagnostic Classification SHI Score (PDQ-R Score) Borderline Group n for SHI (n for PDQ-R) Nonborderline Group n for SHI (n for PDQ-R) 0 (0) 0 (0) 0 (0) 1 (1) 2 (0) 0 (2) 2 (2) 1 (1) 2 (2) 3 (3) 1 (1) 1 (0) 4 (4) 1 (7) 0 (1) 5 (5) 1 (2) 1 (0) 6 (6) 2 (5) 0 (0) 7 (7) 2 (8) 1 (0) 8 (8) 2 (3) 0 (0) 9 5 0 10 or greater 10 0 SHI Score: M (SD) 8.48 (4.11) 3.80 (2.17) PDQ-R Score: M (SD) 5.67 (1.66) 2.00 (1.23) Note. Borderline designation is based on a semistructured clinical interview using DSM-IV (American Psychiatric Association, 1994) diagnostic criteria.

980 Journal of Clinical Psychology, November 1998 Discussion To our knowledge, the SHI is the first measure of self-harm behaviors that predicts for a diagnosis of BPD. In its development, SHI scores of 5 or greater were indicative of BPD according to the DIB and a score of 5 accurately classified nearly 84% of individuals with and without DIB-diagnosed BPD. During subsequent studies, the SHI continued to show acceptable clinical accuracy as a screening measure for the diagnosis of borderline personality disorder. If the diagnostic potential of this measure continues to be reaffirmed in future studies, the SHI may prove useful for both clinicians and researchers. For the clinician, the SHI is a practical measure to administer and score. It is brief, self-report in format, and provides informative data about clinically-relevant self-harm behaviors in which the patient has engaged. Although not used in the scoring, many of the SHI items provide additional information regarding the number of times a patient has engaged in a self-destructive act, as well as how recently he or she has done so. The scoring of the instrument is easily determined by counting the number of different endorsed self-harm behaviors. Given the current data, a score of 5 or greater should prompt the clinician to perform a more formal clinical assessment for BPD. In the clinical setting, the SHI could facilitate the clinician s initiation of the treatmententry contract. By assessing the patient s pattern of self-destructive behavior, the clinician can readily determine high-lethal versus low-lethal self-harm behaviors in a given patient, setting the stage for the negotiation of a treatment entry contract (Sansone, Fine, & Sansone, 1994; Sansone & Johnson, 1995). In addition, the SHI may function as a very useful screening tool in large mental health clinics or in settings where the prevalence of borderline personality is fairly high (e.g., intensive treatment programs for patients with eating disorders [Sansone, Fine, Seuferer, & Bovenzi, 1989; Sansone et al., 1995; Dennis & Sansone, 1997]). The relationship between different dimensions of self-harm behavior and psychiatric manifestation has not been studied to any significant degree. For example, although we did not examine the relationship between active versus passive forms of self-destructive behavior, we suspect that the number of behaviors predicts borderline personality disorder, whereas the type of behaviors (i.e., active versus passive) predicts the functional level of the individual. In other words, more passive self-destructive behavior probably predicts higher-functioning in individuals compared with more active self-destructive behavior. This hypothesis requires research for confirmation. From a research perspective, further development of the SHI may facilitate research on self-destructive behavior and borderline personality symptomatology. Compared with the administration of the DIB, which is labor-intensive, the SHI might serve as an economical proxy measure, particularly if used as an economical proxy measure, particularly if used as an initial screening instrument. By determining the SHI cutoff score to use in a given study, the researcher may be able to adjust the degree of diagnostic sensitivity and rate of falsepositives to suit his or her particular research needs. For example, if the researcher is interested in identifying individuals who may meet the diagnostic criteria for BPD and intends for a more detailed assessment based on results of an initial screening, choosing an SHI cutoff score of 4 may include approximately 90% of individuals who meet diagnostic criteria. On the other hand, to ensure a high probability that screened individuals have BPD, one might adopt an SHI cutoff score of 10. As a final example, if the researcher wishes to ensure that individuals in a given study do not exhibit characteristics of BPD, excluding individuals who endorse more than one or two items may be appropriate. It is important to note that most of the samples studied in the development of the SHI consisted of higher-functioning individuals (i.e., most participants were not recruited

Self-Harm Inventory 981 from community mental health or state hospital settings, which are typical treatment sites for lower-functioning individuals with BPD). This has several potential implications. First, higher-functioning individuals may demonstrate less graphic and less high-lethal behaviors compared with lower-functioning individuals. The potential impact of these differences among populations on the SHI is unknown. However, this difference in functionality may have little effect on the SHI, which should identify many of these behaviors through items such as, overdosed, cut yourself on purpose, and attempted suicide. A second implication of studying the SHI in higher functioning populations is its potentially broader clinical utility. Lower-functioning patients with BPD are a small subset of the broader population with the disorder. Throughout the development of the SHI, it was our intent to assess self-harm behaviors in more functional populations that would be more representative of the borderline population as a whole. We believe that an instrument that is sensitive in better-adapted populations is likely to be equally predictive in more dysfunctional populations. The third implication of studying the SHI in higher-functioning populations is its diagnostic usefulness. From a clinical perspective, higher-functioning borderline patients can be more diagnostically elusive than lower-functioning patients. The SHI may be a useful diagnostic screening measure for higher-functioning patients where the diagnosis may be more difficult to determine, as these individuals are typically employed, educated, and better socially adapted. Several limitations are important to note. First, the SHI is a self-report measure and therefore dependent upon respondents candor, awareness, and comprehension of items. Second, most research participants have been women and more research with men is important. Third, some of the participants in Study 3 may have been reluctant to acknowledge self-harm behavior as suggested by pathological responses in the interview and on the PDQ-R without endorsement of self-harm behaviors on the SHI. Despite reassurance with regard to anonymity, some participants may have feared the implications of their responses (i.e., longer stay). Finally, there is a need to examine the temporal stability of this measure in participant pools. It is important to stress that the SHI explores concrete behaviors. It does not require interpretive or global judgement by respondents, nor does it entail significant quantification of behaviors. Likewise, it is not based upon a theoretical construct for the disorder, but rather the association between self-harm behaviors and BPD. In summary, the SHI may be a useful screening measure for both clinicians and researchers. We emphasize that this measure has just completed its initial development and validation. Additional research in broader populations is needed to further validate the utility of the SHI in distinguishing between those with and those without BPD. In our own clinical experience, the SHI has been a useful measure of self-destructive potential, as well as a practical adjunct to the diagnosis of BPD. REFERENCES American Psychiatric Association. (1987). Diagnostic and statistical manual of mental disorders (3rd ed., rev.). Washington, DC: Author. American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. Armelius, B.A., Kullgren, G., & Renberg, E. (1985). Reliability and validity of Gunderson s Diagnostic Interview for Borderlines. Journal of Nervous and Mental Disease, 168, 428 435. Clark, L.A. (1993). Manual for the Schedule for Nonadaptive and Adaptive Personality (SNAP). Minneapolis: University of Minnesota Press.

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