Non-suicidal self-injury (NSSI) is the act of an individual deliberately and repeatedly injuring his or her own bodily tissues without clear suicidal intent, commonly in the form of cuts, bruises, burns, scratches, bites, hitting the head against a hard object, etc. These acts are not fatal but are extremely dangerous[1]. NSSI has a high global prevalence, especially occurring in adolescents, for example: the detection rate of NSSI among community adolescents is 13.0–46.5% in the United States, 17.0% in Canada, 6.2% in Australia[2], and 27.4% in China[3]. The recurrence rate of NSSI is high and increasing year by year [4], which has seriously endangered the physical and mental health of adolescents[5]. NSSI has been shown to be strongly associated with suicidal behavior [6, 7], increasing the risk of suicidal behavior sevenfold [8] and being a significant predictor of suicidal behavior in adolescents[2], which has become a global concern for public health concern [9].
Much of the current research has focused on exploring risk factors or positive factors for the occurrence of NSSI in adolescents. Results showed that NSSI was associated with higher levels of alexithymia, depression, anxiety, bullying, impulsivity, substance abuse, history of abuse and sexual problems[10], as well as lower levels of mindfulness, resilience and self-esteem[11]. However, few studies have explored the underlying mechanisms between these factors. With the current study, we found that resilience mediates the relationship between narrative disorder and NSSI, with loneliness playing a moderating role. This finding provides more ideas for future psychotherapy programs, as current psychotherapy programs for adolescents with NSSI are mainly based on avoidance approaches [12], and in the future we can adopt more positive psychology approaches to effectively reduce or control NSSI.
1.1 Alexithymia In Nssi
Alexithymia, a term initially coined by Nemiah and Sifneos[13], is not an independent disorder, but a psychological trait that accompanies the development of personality, mainly in that the individual has difficulties in recognizing emotions, has a thin emotional experience and is not concerned with his or her inner world, much less understanding and recognizing the emotions of others[14]. Multiple studies have shown that narrative impairment is positively associated with increased suicide risk in depressed patients[15]. International literature reports alexithymia as one of the potential risks most closely associated with self-harm [16–18]. The cognitive approach of people with alexithymia is conditioned by external stimuli, resulting in difficulties in recognizing and expressing emotions, impaired extroverted thinking and impaired imagination[19]. Research has shown that alexithymia in adolescents is strongly associated with self-harm[20–22], and the severity of alexithymia is significantly higher in patients with repeated self-injury (> 5 times/year) than in occasional self-injury patients (< 5 times/year)[23]. A study confirmed that alexithymia was a significant predictor of NSSI at 5 months of age, suggesting that depression and alexithymia may be predictors of NSSI[11].
At present, experience-avoidance theory holds that NSSI is an avoidance method chosen by individuals who, when faced with negative stimuli, exhibit an impaired ability to express emotions as a way to release negative emotions[24]. Alexithymia has been shown to be an important construct that, in combination with problematic emotions, may lead to a tendency for people with depression to use NSSI to escape intense emotional experiences, or as an alternative form of emotional expression[19]. NSSI is often hidden and difficult to detect in time, especially in the case of adolescents with alexithymia. Long-term repeated NSSI will have an adverse effect on adolescent mental health and considerably increase their suicide risk.
1.2 The Mediated Effect Of Resilience In Alexithymia And Nssi
Resilience is a positive inner protective force, and it helps an individual to maintain a sense of continuity with respect to their survival goals. It constitutes a lateral attitude that can be understood as the ability to overcome difficulties experienced in different areas of life, with an attitude of perseverance and a sound awareness of oneself and one's inner coherence through the activation of personal growth projects[25]. Resilience, as a person's mental capacity and internal resource, can be seen as a dynamic process that is constantly self-regulation and developing as the person grows[26]. Resilience can help teenagers to understand what they need to do when faced with difficulties. It can help them to find ways to prevent long-term psychological distress and maintain a normal developmental trajectory, while encouraging the creation of meaning to help them to make sense of their situation and identity[27]. A study on patients with depression found that alexithymia was negatively correlated with resilience[28]. Individuals with high levels of resilience can use more psychological resources to buffer the adverse effects of alexithymia on suicidal ideation and behavior[29]. In a correlation analysis of alexithymia and resilience among nursing undergraduates, an impaired ability to actively communicate with others and perceive the emotional changes of patients was associated with decreased levels of resilience[30]. At the same time, resilience can actively restructure an individual’s psychology, encourage a healthy and balanced state of mind, and prevent the formation of suicidal ideation[31].
Resilience as a positive factor has been shown in many studies to mediate between many psychological factors. Several Chinese studies have shown that resilience has the mediated effect between childhood abuse and suicidal ideation in adolescents[32], resilience has the mediated effect between physical fitness and anxiety in children[33], and resilience has the mediated effect between school bullying and anxiety in adolescents[34]. It has also been shown that resilience has the mediated effect between loneliness and depressive symptoms in elderly people in nursing homes[35]. The study found that alexithymia can significantly predict resilience and NSSI, while resilience has the mediated effect between alexithymia and NSSI[12]. This is consistent with the findings in this paper that alexithymia negatively predicts resilience and positively predict NSSI, and that the relationship between alexithymia and NSSI can be influenced through the mediated effect of resilience.
1.3 The Relationship Between Loneliness And Other Psychological Factors
The American psychologist L.S.Hollingworth refers to the period between adolescence and early youth as the "psychological weaning period". This period is a time of great anxiety for adolescents. Although they have a subjective need and desire to be independent, it is difficult for them to adapt to independent living in a short period of time. There are many problems that they cannot solve on their own and they are reluctant to ask their parents or others for help, fearing that this may compromise their independence. In addition, the need for intimacy at this time, but the social relationships associated with it, have not yet been established, so when they fall into a state of isolation, it is often difficult for them to extricate themselves. Loneliness in this period is a chronic pervasive state of mind.[36]. Loneliness, as a negative emotion, has been identified as a predisposing factor for depression and is a common condition with affective, cognitive, and motivational scales[37]. An association was observed between loneliness and NSSI, with higher levels of loneliness associated with a higher likelihood of NSSI[38]. The Interpersonal Functional Model of NSSI proposes that there are important links between interpersonal experiences and NSSI[39]. Loneliness, for example, is a negative interpersonal experience that is often serve as precipitants to NSSI[40].
Chronic loneliness threatens an individual's future mental health and a number of indicators regarding psychosocial functioning[41]. Research on loneliness has shown that it is associated with a range of risk or protective factors strongly associated with NSSI, including lack of alexithymia [42], stress, social deficits[43], low self-esteem[44], resilience, mental health, mental and physical quality of life[45]. Some aspects of alexithymia may lead to mistrust, and this mistrust interacts with the initial alexithymia to produce a range of interpersonal problems that lead to loneliness[41]. Many articles have begun to explore the relationship between loneliness and these risk or protective factors. Some studies have shown that higher levels of loneliness are associated with lower levels of mental health and resilience, and that loneliness, resilience and mental health all affect mental and physical quality of life[46]. We found that resilience can reduce the impact of loneliness on the physical and mental health of people with depression. Some studies have shown that adolescents with poor emotional regulation increase their feelings of loneliness over time, while adolescents with high emotional regulation can successfully overcome loneliness by perceiving and managing the negative emotions associated with it[47]. Loneliness persists in adolescence, but as adolescents grow older, they become more mature in their interpersonal relationships, have more friends and have less relationships with their families. This is when adolescents' feelings of loneliness change, and this change will certainly affect other psychological factors, which this study will explore.
1.4 The Current Study
Although there are known empirical relationships between alexithymia, resilience, loneliness, and NSSI, no empirical investigation has been carried out to examine the exact nature of these relationships. Based on the above discussion, the research assumptions of this paper are as follows:
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Among adolescents with depression, resilience would mediate the relation between alexithymia and NSSI.
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Loneliness would moderate the direct and indirect relationships between alexithymia and resilience.
It is hoped that the results of this cross-sectional study can provide a theoretical basis for therapists to strengthen adolescents' psychological elasticity and alleviate symptoms of alexithymia by developing effective psychological interventions that draw on a positive psychology perspective, so as to effectively manage NSSI in this population.