Korean Clinical Psychology Association

Korean Journal of Clinical Psychology - Vol. 37 , No. 4

[ Original Article ]
Korean Journal of Clinical Psychology - Vol. 37 , No. 4 , pp.465-478
ISSN: 2733-4538 (Online)
publication date 30 Nov 2018
Received 21 May 2018 Revised 13 Sep 2018 Accepted 18 Sep 2018
DOI: https://doi.org/10.15842/kjcp.2018.37.4.001

우울증 환자 집단에서 비자살적자해가 자살시도에 미치는 영향
김초롱 1 ; 이승환 2 ; 장혜인 1,
1성균관대학교 심리학과
2일산백병원 정신건강의학과

Influence of Non-Suicidal Self-Injury on Suicide Attempt among Depressed Patients
Cho Long Kim1 ; Seung-Hwan Lee2 ; Hyein Chang1,
1Department of Psychology, Sungkyunkwan University, Seoul
2Department of Psychiatry, Ilsan-Paik Hospital, College of Medicine, Inje University, Goyang, Korea
Correspondence to : Hyein Chang, Department of Psychology, Sungkyunkwan University, 25-2 Sungkyunkwan-ro, Jongno-gu, Seoul, Korea; E-mail: hichang @skku.edu

© 2018 Korean Clinical Psychology Association


자살은 여타 병리와 다르게 완수될 경우 돌이킬 방법이 전혀 없다는 점에서 학술적, 임상적 주의가 요구되는 병리적 행동으로, 자살률이 높은 한국사회에서는 그 예방적 중요성이 더욱 크다고 할 수 있다. 그간 다양한 이론들이 자살을 설명하기 위해 주력해왔으며, 본 연구는 자살에 대한 최신 이론인 대인관계적 심리이론에서 제안된 개념인 습득된 자살잠재력과 자살욕구를 통해 비자살적자해와 자살시도 간의 관계를 설명하고자 하였다. 그러나 비자살적자해와 자살시도 간의 관계에서 습득된 자살잠재력과 자살욕구를 모두 살펴보아야 할 필요성에도 불구하고, 이를 통합적으로 검증한 연구는 거의 없었다. 본 연구에서는 우울증상을 경험하고 있는 정신건강의학과 환자군 91명을 대상으로 비자살적자해, 습득된 자살잠재력, 자살욕구, 자살시도 횟수를 자기보고식 질문지와 압통계, 구조화된 면담을 통해서 측정하였다. 분석 결과, 비자살적자해는 습득된 자살잠재력의 하위요인인 죽음에 대한 두려움의 감소를 유의하게 예측하지 못했던 반면, 또 다른 하위요인인 통증인내력 매개를 거쳐 자살시도를 유의하게 예측하는 것으로 나타났다. 더불어, 통증인내력이 자살시도를 예측하는 데 있어 자살욕구의 수준이 유의한 조절효과를 보였다. 비자살적자해와 통증인내력, 자살욕구 그리고 자살시도를 모두 포함한 통합적 모형에 대한 조절된 매개분석 결과, 비자살적자해가 통증인내력 매개를 거쳐 자살시도를 예측할 때, 자살욕구가 통증인내력이 자살시도로 이어지는 경로를 유의하게 조절하는 것으로 나타났다. 이러한 결과들은 자살시도와 유의한 상관을 나타낸 흡연과 우울 공변인의 효과를 통제한 이후에도 마찬가지로 유의했다. 위와 같은 결과를 통해 본 연구는 비자살적자해가 자살시도의 횟수를 높이는 데 있어 습득된 자살잠재력과 자살욕구가 어떠한 역할을 하는지 살펴보았으며, 이러한 기제는 그간 자살에 대한 위험요인으로 알려진 우울증상의 수준을 통제한 이후에도 유의하다는 것을 확인하였다. 마지막으로 이러한 결과를 바탕으로 본 연구의 한계점과 이론적, 임상적 의의를 논하였다.


Suicide is a pathological behavior that requires academic and clinical attention because it cannot be undone once accomplished. Prevention of suicide is especially important in South Korea, as the suicide rate is alarmingly high. This study aimed to investigate the relationship between non-suicidal self-injury and suicide attempt considering the roles of the acquired capability for suicide and suicidal desire, which are the concepts proposed in the interpersonal psychological theory, the latest theory of suicide. A total 91 psychiatric patients with reported depressive symptoms provided data on non-suicidal self-injury, acquired capability for suicide, suicidal desire, and the number of lifetime suicide attempts using self-report inventories. Additionally we used a pressure algometer and structured interview. Results indicated that non-suicidal self-injury significantly predicted suicide attempt, mediated by pain tolerance, which is one of the subcomponents of acquired capability for suicide. Furthermore, suicidal desire moderated the relationship between pain tolerance and suicide attempt. Lastly, pain tolerance mediated the relationship between non-suicidal self-injury and suicide attempt when suicidal desire was high but not when suicidal desire was low. Results were still significant after controlling for the effects of smoking and depressive symptoms. Implications and limitations of the study are discussed.

Keywords: non-suicidal self-injury, acquired capability for suicide, suicidal desire, suicide attempt
키워드: 비자살적자해, 습득된 자살잠재력, 자살욕구, 자살시도


The present article is based on a master's thesis study conducted by the first author under the guidance of the third author.

1. Aiken, L. S., West, S. G., & Reno, R. R. (1991). Multiple regression: Testing and interpreting interactions. Newbury Park, CA: Sage.
2. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed). Washington, DC: American Psychiatric Association.
3. Andover, M. S., & Gibb, B. E. (2010). Non-suicidal self-injury, attempted suicide, and suicidal intent among psychiatric inpatients. Psychiatry Research, 178, 101-105.
4. Anestis, M. D., Bagge, C. L., Tull, M. T., & Joiner, T. E. (2011). Clarifying the role of emotion dysregulation in the interpersonal-psychological theory of suicidal behavior in an undergraduate sample. Journal of Psychiatric Research, 45, 603-611.
5. Anestis, M. D., & Capron, D. W. (2016). An investigation of persistence through pain and distress as an amplifier of the relationship between suicidal ideation and suicidal behavior. Journal of Affective Disorders, 196, 78-82.
6. Anestis, M. D., & Joiner, T. E. (2011). Examining the role of emotion in suicidality: Negative urgency as an amplifier of the relationship between components of the interpersonal–psychological theory of suicidal behavior and lifetime number of suicide attempts. Journal of Affective Disorders, 129, 261-269.
7. Brausch, A. M., & Gutierrez, P. M. (2010). Differences in non-suicidal self-injury and suicide attempts in adolescents. Journal of Youth and Adolescence, 39, 233-242.
8. Briere, J., & Gil, E. (1998). Self‐mutilation in clinical and general population samples: Prevalence, correlates, and functions. American Journal of Orthopsychiatry, 68(4), 609-620.
9. Brown, M. Z., Comtois, K. A., & Linehan, M. M. (2002). Reasons for suicide attempts and non-suicidal self-injury in women with borderline personality disorder. Journal of Abnormal Psychology, 111, 198-202.
10. Bryan, C. J. (2011). The clinical utility of a brief measure of perceived burdensomeness and thwarted belongingness for the detection of suicidal military personnel. Journal of Clinical Psychology, 67, 981-992.
11. Bryan, C. J., Cukrowicz, K. C., West, C. L., & Morrow, C. E. (2010). Combat experience and the acquired capability for suicide. Journal of Clinical Psychology, 66, 1044-1056.
12. Bryan, C. J., Morrow, C. E., Anestis, M. D., & Joiner, T. E. (2010). A preliminary test of the interpersonal-psychological theory of suicidal behavior in a military sample. Personality and Individual Differences, 48, 347-350.
13. Christensen, H., Batterham, P. J., Soubelet, A., & Mackinnon, A. J. (2013). A test of the interpersonal theory of suicide in a large community-based cohort. Journal of Affective Disorders, 144, 225-234.
14. Curran, P. J., West, S. G., & Finch, J. F. (1996). The robustness of test statistics to nonnormality and specification error in confirmatory factor analysis. Psychological Methods, 1, 16-29.
15. Didham, R. C., McConnell, D. W., Blair, H. J., & Reith, D. M. (2005). Suicide and self‐harm following prescription of SSRIs and other antidepressants: Confounding by indication. British Journal of Clinical Pharmacology, 60, 519-525.
16. Favaro, A., Santonastaso, P., Monteleone, P., Bellodi, L., Mauri, M., Rotondo, A., . . . & Maj, M. (2008). Self-injurious behavior and attempted suicide in purging bulimia nervosa: Associations with psychiatric comorbidity. Journal of Affective Disorders, 105, 285-289.
17. Favazza, A. R. (1996). Bodies under siege: Self-mutilation and body modification in culture and psychiatry. (2nd ed.). Baltim ore, MD: Johans Hopkins University Press.
18. Fishbain, D. (2000). Evidence-based data on pain relief with antidepressants. Annals of Medicine, 3, 305-316.
19. Fournier, J. C., DeRubeis, R. J., Hollon, S. D., Dimidjian, S., Amsterdam, J. D., Shelton, R. C., & Fawcett, J. (2010). Antidepressant drug effects and depression severity: A patient-level meta-analysis. Journal of the American Medical Association, 303, 47-53.
20. Fragoso, Y. D., Frota, E. R. C., Lopes, J. S., Noal, J. S., Giacomo, M. C., Gomes, S., . . . Finkelsztejn, A. (2010). Severe depression, suicide attempts, and ideation during the use of interferon beta by patients with multiple sclerosis. Clinical Neuropharmacology, 33, 312-316.
21. Franklin, J. C., Aaron, R. V., Arthur, M. S., Shorkey, S. P., & Prinstein, M. J. (2012). Non-suicidal self-injury and diminished pain perception: The role of emotion dysregulation. Comprehensive Psychiatry, 53, 691-700.
22. George, S. E., Page, A. C., Hooke, G. R., & Stritzke, W. G. (2016). Multifacet assessment of capability for suicide: Development and prospective validation of the Acquired Capability with Rehearsal for Suicide Scale. Psychological Assessment, 28, 1452-1464.
23. Glenn, C. R., & Klonsky, E. D. (2009). Social context during non-suicidal self-injury indicates suicide risk. Personality and Individual Differences, 46, 25-29.
24. Groschwitz, R. C., & Plener, P. L. (2012). The neurobiology of non-suicidal self-injury (NSSI): A review. Suicidology Online, 3, 24-32.
25. Guertin, T., Lloyd-Richardson, E., Spirito, A., Donaldson, D., & Boergers, J. (2001). Self-mutilative behavior in adolescents who attempt suicide by overdose. Journal of the American Academy of Child & Adolescent Psychiatry, 40, 1062-1069.
26. Hamza, C. A., Stewart, S. L., & Willoughby, T. (2012). Examining the link between non-suicidal self-injury and suicidal behavior: A review of the literature and an integrated model. Clinical Psychology Review, 32, 482-495.
27. Hawkins, K. A., Hames, J. L., Ribeiro, J. D., Silva, C., Joiner, T. E., & Cougle, J. R. (2014). An examination of the relationship between anger and suicide risk through the lens of the interpersonal theory of suicide. Journal of Psychiatric Research, 50, 59-65.
28. Hayes, A. F. (2016). The PROCESS macro for SPSS and SAS. URL: http://www.processmacro.org/index.html (visited on 12/07/ 2017).
29. Hayes, A. F. (2017). Introduction to mediation, moderation, and conditional process analysis: A regression-based approach. New York, NY: Guilford Publications.
30. Hemmingsson, T., & Kriebel, D. (2003). Smoking at age 18-20 and suicide during 26 years of follow-up up— How can the association be explained?. International Journal of Epidemiology, 32, 1000-1004.
31. Jacobson, C. M., Muehlenkamp, J. J., Miller, A. L., & Turner, J. B. (2008). Psychiatric impairment among adolescents engaging in different types of deliberate self-harm. Journal of Clinical Child & Adolescent Psychology, 37, 363-375.
32. Jo, M. H. (2010). Evaluation of Interpersonal psychological model of suicide in Korean army (Unpublished master’s thesis). Korea University, Seoul, Korea.
33. Joiner, T. (2007). Why people die by suicide. Cambridge, MA: Harvard University Press.
34. Joiner, T. E. Jr., Rudd, M. D., & Rajab, M. H. (1997). The Modified Scale for Suicidal Ideation: Factors of suicidality and their relation to clinical and diagnostic variables. Journal of Abnormal Psychology, 106, 260.
35. Joiner, T. E. Jr., Sachs-Ericsson, N. J., Wingate, L. R., Brown, J. S., Anestis, M. D., & Selby, E. A. (2007). Childhood physical and sexual abuse and lifetime number of suicide attempts: A persistent and theoretically important relationship. Behaviour Research and Therapy, 45, 539-547.
36. Joiner, T. E. Jr., Van Orden, K. A., Witte, T. K., Selby, E. A., Ribeiro, J. D., Lewis, R., & Rudd, M. D. (2009). Main predictions of the interpersonal-psychological theory of suicidal behavior: Empirical tests in two samples of young adults. Journal of Abnormal Psychology, 118, 634-646.
37. Kessler, R. C., Berglund, P., Borges, G., Nock, M., & Wang, P. S. (2005). Trends in suicide ideation, plans, gestures, and attempts in the United States, 1990-1992 to 2001-2003. Journal of the American Medical Association, 293, 2487-2495.
38. Kim, J. H. (2014). Influence of acquired capabilities for suicide on adolescents’ suicide attempt (Unpublished master’s thesis). Yeungnam University, Kyungsan, Korea.
39. Klonsky, E. D. (2011). Non-suicidal self-injury in United States adults: Prevalence, sociodemographics, topography and functions. Psychological Medicine, 41, 1981-1986.
40. Klonsky, E. D., May, A. M., & Glenn, C. R. (2013). The relationship between non-suicidal self-injury and attempted suicide: Converging evidence from four samples. Journal of Abnormal Psychology, 122, 231-237.
41. Klonsky, E. D., & Muehlenkamp, J. J. (2007). Self‐injury: A research review for the practitioner. Journal of Clinical Psychology, 63, 1045-1056.
42. Klonsky, E. D., Oltmanns, T. F., & Turkheimer, E. (2003). Deliberate self-harm in a nonclinical population: Prevalence and psychological correlates. American Journal of Psychiatry, 160(8), 1501-1508.
43. Kwon, H. J. (2014). Exploration of emotional and cognitive factors influencing non-suicidal self-injury (Unpublished master’s thesis). Seoul University, Seoul, Korea.
44. Kwon, Y. S., Lee, H. Y., Kim, S. C., & Hyun, M. H. (2016). The Effects of thwarted interpersonal needs on perceived sense of no meaning and purpose about life and physical pain tolerance. The Korean Journal of Health Psychology, 21, 877-893.
45. Law, K. C., Khazem, L. R., Jin, H. M., & Anestis, M. D. (2017). Non-suicidal self-injury and frequency of suicide attempts: The role of pain persistence. Journal of Affective Disorders, 209, 254-261.
46. Lee, C. S. (2011). A study of the reliability and validity of the Colombia-Suicide Severity Rating Scale in Korea (Unpublished master’s thesis). Inje University, Kimhae, Korea.
47. Linehan, M. M. (1986). One population or two?. Annals of the New York Academy of Sciences, 487, 16-33.
48. Lloyd, E. E., Kelley, M. L., & Hope, T. (1997, April). Self-mutilation in a community sample of adolescents: Descriptive characteristics and provisional prevalence rates. Poster session presented at annual meeting of the Society for Behavioral Medicine, New Orleans, LA.
49. Lloyd-Richardson, E. E., Perrine, N., Dierker, L., & Kelley, M. L. (2007). Characteristics and functions of non-suicidal self-injury in a community sample of adolescents. Psychological Medicine, 37, 1183-1192.
50. Matney, J., Westers, N. J., Horton, S. E., King, J. D., Eaddy, M., Emslie, G. J., . . . & Stewart, S. M. (2018). Frequency and methods of non-suicidal self-injury in relation to acquired capability for suicide among adolescents. Archives of Suicide Research, 22, 91-105.
51. Muehlenkamp, J. J., & Gutierrez, P. M. (2004). An investigation of differences between self-injurious behavior and suicide attempts in a sample of adolescents. Suicide and Life-Threatening Behavior, 34, 12-23.
52. Muehlenkamp, J. J., & Gutierrez, P. M. (2007). Risk for suicide attempts among adolescents who engage in non-suicidal self-injury. Archives of Suicide Research, 11, 69-82.
53. Muehlenkamp, J. J., Swenson, L. P., Batejan, K. L., & Jarvi, S. M. (2015). Emotional and behavioral effects of participating in an online study of non-suicidal self-injury: An experimental analysis. Clinical Psychological Science, 3, 26-37.
54. Nock, M. K. (2009). Why do people hurt themselves? New insights into the nature and functions of self-injury. Current Directions in Psychological Science, 18, 78-83.
55. Nock, M. K. (2010). Self-injury. Annual Review of Clinical Psychology, 6, 339-363.
56. Nock, M. K., Joiner, T. E., Gordon, K. H., Lloyd-Richardson, E., & Prinstein, M. J. (2006). Non-suicidal self-injury among adolescents: Diagnostic correlates and relation to suicide attempts. Psychiatry Research, 144, 65-72.
57. Nock, M. K., & Kessler, R. C. (2006). Prevalence of and risk factors for suicide attempts versus suicide gestures: Analysis of the National Comorbidity Survey. Journal of Abnormal Psychology, 115, 616-623.
58. Nock, M. K., & Prinstein, M. J. (2004). A functional approach to the assessment of self-mutilative behavior. Journal of Consulting and Clinical Psychology, 72, 885.
59. Park, Y. S. (2017). The interaction effects between personality and interpersonal needs in predicting current suicide ideation (Unpublished master’s thesis). Sogang University, Seoul, Korea.
60. Phillips, M. R. (2010). Rethinking the role of mental illness in suicide. Unpublished manuscript.
61. Plener, P. L., Libal, G., Keller, F., Fegert, J. M., & Muehlenkamp, J. J. (2009). An international comparison of adolescent non-suicidal self-injury (NSSI) and suicide attempts: Germany and the USA. Psychological Medicine, 39, 1549-1558.
62. Posner, K., Brodsky, B., Yershova, K., Buchanan, J., & Mann, J. (2014). The classification of suicidal behavior. In M. Nock (Ed.), The Oxford handbook of suicide and self-injury (pp. 7-22). Oxford, UK: Oxford University Press.
63. Posner, K., Oquendo, M. A., Gould, M., Stanley, B., & Davies, M. (2007). Columbia Classification Algorithm of Suicide Assessment (C-CASA): Classification of suicidal events in the FDA’s pediatric suicidal risk analysis of antidepressants. American Journal of Psychiatry, 164, 1035-1043.
64. Preacher, K. J., & Hayes, A. F. (2004). SPSS and SAS procedures for estimating indirect effects in simple mediation models. Behavior Research Methods, 36, 717-731.
65. Preacher, K. J., & Hayes, A. F. (2008). Asymptotic and resampling strategies for assessing and comparing indirect effects in multiple mediator models. Behavior Research Methods, 40, 879-891.
66. Ribeiro, J. D., Witte, T. K., Van Orden, K. A., Selby, E. A., Gordon, K. H., Bender, T. W., & Joiner, T. E. Jr. (2014). Fearlessness about death: The psychometric properties and construct validity of the revision to the Acquired Capability for Suicide Scale. Psychological Assessment, 26, 115-126.
67. Rudd, M. D. (1989). The prevalence of suicidal ideation among college students. Suicide and Life‐Threatening Behavior, 19, 173-183.
68. Smith, P. N., Cukrowicz, K. C., Poindexter, E. K., Hobson, V., & Cohen, L. M. (2010). The acquired capability for suicide: A comparison of suicide attempters, suicide ideators, and non‐suicidal controls. Depression and Anxiety, 27, 871-877.
69. Smith, P. N., Wolford-Clevenger, C., Mandracchia, J. T., & Jahn, D. R. (2013). An exploratory factor analysis of the Acquired Capability for Suicide Scale in male prison inmates. Psychological Services, 10, 97-105.
70. Solomon, R. L. (1980). The opponent-process theory of acquired motivation: The costs of pleasure and the benefits of pain. American Psychologist, 35, 691.
71. Stanley, B., Winchel, R., Molcho, A., Simeon, D., & Stanley, M. (1992). Suicide and the self-harm continuum: Phenomenological and biochemical evidence. International Review of Psychiatry, 4, 149-155.
72. Tang, J., Yu, Y., Wu, Y., Du, Y., Ma, Y., Zhu, H., . . . Liu, Z. (2011). Association between non-suicidal self-injuries and suicide attempts in Chinese adolescents and college students: A cross-section study. PLoS One, 6, e17977.
73. Thomas, H. V., Crawford, M., Meltzer, H., & Lewis, G. (2002). Thinking life is not worth living. Social Psychiatry and Psychiatric Epidemiology, 37, 351-356.
74. Van Orden, K. A., Cukrowicz, K. C., Witte, T. K., & Joiner, T. E. Jr. (2012). Thwarted belongingness and perceived burdensomeness: Construct validity and psychometric properties of the Interpersonal Needs Questionnaire. Psychological Assessment, 24, 197.
75. Van Orden, K. A., Witte, T. K., Cukrowicz, K. C., Braithwaite, S. R., Selby, E. A., & Joiner, T. E. Jr. (2010). The interpersonal theory of suicide. Psychological Review, 117, 575-600.
76. Van Orden, K. A., Witte, T. K., Gordon, K. H., Bender, T. W., & Joiner, T. E. Jr. (2008). Suicidal desire and the capability for suicide: tests of the interpersonal-psychological theory of suicidal behavior among adults. Journal of Consulting and Clinical Psychology, 76, 72-83.
77. Van Orden, K. A., Witte, T. K., James, L. M., Castro, Y., Gordon, K. H., Braithwaite, S. R., . . . & Joiner, T. E. Jr. (2008). Suicidal ideation in college students varies across semesters: The mediating role of belongingness. Suicide and Life-Threatening Behavior, 38, 427-435.
78. Van Ree, J. M., Niesink, R. J., Van Wolfswinkel, L., Ramsey, N. F., Van Furth, W. R., Vanderschuren, L. J., . . . & Van den Berg, C. L. (2000). Endogenous opioids and reward. European Journal of Pharmacology, 405, 89-101.
79. Whitlock, J., Muehlenkamp, J., & Eckenrode, J. (2008). Variation in non-suicidal self-injury: Identification and features of latent classes in a college population of emerging adults. Journal of Clinical Child & Adolescent Psychology, 37, 725-735.
80. Wilcox, H. C., Arria, A. M., Caldeira, K. M., Vincent, K. B., Pinchevsky, G. M., & O’Grady, K. E. (2012). Longitudinal predictors of past-year non-suicidal self-injury and motives among college students. Psychological Medicine, 42, 717-726.
81. Wilkinson, P., Kelvin, R., Roberts, C., Dubicka, B., & Goodyer, I. (2011). Clinical and psychosocial predictors of suicide attempts and non-suicidal self-injury in the Adolescent Depression Antidepressants and Psychotherapy Trial (ADAPT). American Journal of Psychiatry, 168, 495-501.
82. Willoughby, T., Heffer, T., & Hamza, C. A. (2015). The link between non-suicidal self-injury and acquired capability for suicide: A longitudinal study. Journal of Abnormal Psychology, 124, 1110.
83. Witte, T. K., Joiner, T. E., Brown, G. K., Beck, A. T., Beckman, A., Duberstein, P., & Conwell, Y. (2006). Factors of suicide ideation and their relation to clinical and other indicators in older adults. Journal of Affective Disorders, 94, 165-172.
84. Wong, Y. J., Koo, K., Tran, K. K., Chiu, Y. C., & Mok, Y. (2011). Asian American college students' suicide ideation: A mixed-methods study. Journal of Counseling Psychology, 58, 197.
85. World Health Organization. (2014). Preventing Suicide: a global imperative (pp. 7-11). Geneva, Switzerland: WHO Press.