Self-injurious behaviors, wherein an individual directly and intentionally harms their body, are termed as such. These behaviors encompass non-suicidal self-injury (NSSI), wherein a person deliberately and directly injures their body tissue without the intent to die [1]. NSSI comprises cutting or scratching the skin with a sharp object, hitting oneself, and picking at wounds. Additionally, hitting, burning, and substance abuse are common forms of NSSI as well [2]. Previous studies have categorized the severity of NSSI into three groups based on its forms: mild, moderate, and severe. Mild forms of NSSI include hitting oneself, picking at wounds, and hitting, while moderate/severe forms include cutting, scratching the skin, burning, and substance abuse [3].
Self-injury typically commences in early adolescence, commonly around the ages of 13 to 17 [4]. Meta-analytic studies have reported the lifetime prevalence of NSSI ranging from 6.69–9.2% in children and adolescents, which may vary depending on sample characteristics and assessment methods [5, 6]. However, the overall prevalence has been estimated at 1.22% across the lifespan [7]. NSSI is associated with various psychiatric symptoms. For instance, symptoms of depression and anxiety disorders (especially those involving self-harm) are associated with self-injurious behaviors [8, 9]. Moreover, individuals with borderline personality disorder symptoms have reported higher rates of self-injury compared to those without these symptoms [1].
Such behavior necessitates care and attention from healthcare and therapeutic professionals, as NSSI often desensitizes individuals to physical pain and can increase the long-term risk of suicide. Cohort studies on a large scale conducted in the United States and Britain indicate that the suicide rate among young people with deliberate self-harm behaviors is 30 times higher than the general population [10]. The results of the study by Millon et al. [11] estimated the lifetime prevalence of NSSI in adolescents as follows: (thoughts: 78%; behavior: 72%), in the past year (thoughts: 74%; behavior: 65%), and in the past month (thoughts: 68%; behavior: 51%). Furthermore, recent studies conducted in Iran on the investigation of self-injurious behaviors among high school students report various levels of prevalence throughout life, with the prevalence rates of self-injurious behaviors among girls and boys being 9.6% and 7.1%, respectively [12]. The pattern of self-injurious behaviors in girls compared to boys was less observable and more irregular. Among self-injurious behaviors, deliberate self-harming, deliberate cutting of body parts, engaging in self-destructive behaviors, and self-harming verbalizations had the highest frequency. Additionally, self-injurious behaviors in girls were more internally functioning compared to boys [13].
Most studies have focused on the role of emotional regulation in NSSI, with negative emotional states being proximal risk factors for self-injurious behavior. Further research has emphasized negative emotions as crucial triggers for self-injurious behavior [9, 14, 15]. Emotional regulation involves various neurobiological and physiological processes, such as emotion recognition, emotional responsiveness, and cognitive control [16]. According to Gross's [17] emotion regulation process model, emotions are generated and expressed in a multi-stage process where different emotion regulation strategies are available at each stage. In this model, emotional regulation should include awareness of emotions, goals, and regulation strategies for those emotions (such as increasing or decreasing their intensity), and effective implementation of adaptive strategies to achieve the goal of emotion regulation [18].
The concept of primary maladaptive schemes conceptualizes problems in emotional regulation as a result of early negative life experiences when the fundamental emotional needs of a child are not met [19]. According to the schema framework, adversities in childhood lead to emotional regulation problems through maladaptive schemas, as individuals may not have developed appropriate coping patterns for dealing with experienced emotions [20]. The emotional schema model is a cognitive-social model of how individuals perceive, interpret, evaluate, and respond to their own and others' emotions. All individuals experience a wide range of "distress-producing emotions," including anger, anxiety, sadness, hopelessness, envy, and resentment, but not all individuals develop psychiatric disorders [21]. The emotional schema model suggests that individuals vary in their theories about emotion and emotion regulation, and these psychological theories employ problematic strategies for coping with emotions, such as suppression, rumination, avoidance, self-blame, and substance abuse [22]. For example, individuals who experience separation may feel anger, anxiety, confusion, and relief. If these individuals perceive their experienced emotions as normal and natural (related to events), they can tolerate unpleasant emotions and are "adaptive"; also, if they recognize that these emotions are temporary and not dangerous, and do not feel embarrassed by these emotions, they are unlikely to experience longer-term emotional problems [22]. Conversely, if these individuals believe that these emotions are abnormal, and irrational, and should only experience one side of this emotional experience, these emotions will continue indefinitely using irrational strategies (shame, rumination, avoidance, self-criticism, isolation, and substance abuse) and become out of control [22].
In addition, Leahy and Wupperman [23] suggested that non-adaptive emotional schemas lead to greater emotional instability and increased risk of suicidal or self-harming behaviors when an individual is faced with a distressing situation, such as hopelessness, loss, or other emotional experiences. A study involving adolescents discovered a significant and positive correlation between feelings of abandonment/instability, defect/shame, and six emotional regulation issues [24]. Adolescents with a history of NSSI reported more problems in emotional regulation compared to normal adolescents. Structural equation modeling results showed a direct and positive effect and an indirect positive effect through cognitive emotional regulation between primary maladaptive schemas and NSSI. Pilkington et al. [25] also showed a significant positive relationship between emotional regulation strategies and all 18 maladaptive schemas. Khaleghi et al. [26] in a study aimed at finding emotional schemas of suicide: emotional schemas were associated with suicidal thoughts, self-harm behaviors, and suicidal behaviors. Among these schemas, rumination and invalidation played an important role in predicting high levels of suicidal thoughts and self-harm behaviors.
Despite numerous studies on self-harming behavior in adolescents, no research investigating the mediating role of cognitive-emotional regulation in the relationship between emotional schemas and non-suicidal self-injury (NSSI) has been found. Furthermore, expanding the concept of emotional schemas can be crucial in preventing non-suicidal self-injury because emotional processing difficulties are associated with borderline personality disorder [27]. Additionally, examining the role of emotional information processing in this context may help understand the psychopathology of non-suicidal self-injury and borderline personality disorder and provide an account of the cumulative knowledge for prevention and intervention of self-injurious behaviors. Therefore, the present study aimed to examine the structural pattern of emotional schemas with adolescent self-harming behavior based on the mediating role of cognitive-emotional regulation strategies.