一样自伤两样人：自伤青少年的分类研究
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摘要
病理心理学领域中的自我伤害行为(下文简称自伤)是指个体在没有明确自杀意图的情况下,故意、重复地改变或伤害自己的身体组织,这种行为不被社会所认可,且不具致死性或致死性较低。自伤行为的本质是一种适应不良的应对方式,核心问题是情绪管理障碍。早期创伤经验、情绪管理障碍、冲动性和某些生物学因素被认为是影响自伤的重要因素。自伤行为与很多心理问题或精神障碍相关,并且自伤者的自杀风险远高于普通人群(66倍)。自伤在精神病学和临床心理学等领域已经引起相当程度的关注,也存在非常激烈的争议。2013年出版的DSM-V将自伤作为一种未确定诊断的障碍列入,正反映这种受关注又不确定的状况。青少年是自伤的高发群体,国内流行学调查发现普通初高中生的自伤率超过40%,因此青少年的自伤行为尤其需要被关注。
此前对青少年自伤行为的研究一再发现以下现象：(1)自伤在普通青少年中有超出预期的高发生率(14-56%);(2)不同青少年的自伤有着非常不同的行为学表现；(3)任何单一因素对自伤的解释力均十分有限；(4)自伤的发生率在青少年、青年、成年普通人群中依次递减。对于这些令人费解的现象,本文研究者(作者及其导师)猜测,目前研究者所定义并依据定义选择的自伤群体样本可能是异质的；其内部可能存在不同的亚类,不同亚类自伤的行为学表现、心理学意义,以及影响因素不尽相同；而在自伤的亚类中,可能有一个是非病理性自伤,随着年龄的增长,这类自伤者将逐渐转向健康的应对方式,适应不良的自伤行为将自行停止。
以此认识为基础,本文研究者提出一个自伤青少年的分类假说,包括两个核心假设：(1)全体自伤青少年可以分为两大类,一类可称为病理性自伤,其身心基础、发展历史,以及现时的个体-环境关系存在真正的“病理性”原因；另一类可称之为发展性自伤,其身心基础和发展历史可能基本正常,只是现时个体-环境关系存在不适应情况。(2)两类自伤有着不同的发生机制：病理性自伤是一种病理性行为,自伤行为的发生因个体对某些社会性刺激有高反应敏感性的病理特征,表现为只需要微弱的刺激就会引起个体的高情绪反应；发展性自伤是一种情境性行为,自伤行为的发生主要由外部压力环境导致。
本论文工作的基本目的,即是对此理论假说进行探索和检验。作者共做了5项研究,分别从不同角度对该分类假设进行检验。
研究一,目的是检验自伤青少年是否包含一个异质(病理性)的类别。研究方法采用Taxometric分析法的MAXEIG、MAMBAC和L-Model三种程序。分析指标为《青少年自我伤害行为问卷》得分。由于判断群体异质性的参照对象是普通青少年,因此分析样本为包含有自伤和无自伤行为青少年的混合样本,共1343人。分别来自某市一所普通初中(N=450),一所普通高中(N=518),市工读学校(N=43)和未成年犯管教所(N=332),平均年龄15.77岁(SD=5.40)。其中有自伤行为的青少年582人。L-Mode程序由于指标效度过低而导致结果无效。MAXEIG、MAMBAC程序均显示样本包含一个异质的类别。由于分类指标是症状水平(自伤水平),故该异质类别可视为病理性自伤者,其余为非病理性自伤者。
研究二的目的是采用另一种分类研究方法——潜在剖面图分析(Latent Profile Analysis,LPA),检验自伤青少年可能存在的潜在类别数目,以使之与研究一进行对照,同时也检验所选择的若干分类变量是否可以作为区分不同类别自伤青少年的区分特征。研究对象来自研究一,以有自伤行为的574名青少年为样本。研究方法为潜在剖面图分析(LPA)。分别进行两个LPA分析：第一个以测量自伤的17个条目为指标,检验自伤青少年样本中可能包含的类别数；第二个以自伤、早期创伤经验、父母教养态度、父母管教方式、情绪反应性和情绪调节困难等6个变量为分类指标,检验自伤青少年的类别数和和上述变量作为区分特征的有效性。结果显示两个LPA分析均能且仅能分出两个类别。两类自伤的区分特征与分类假说对“病理性自伤”和“发展性自伤”的描述基本一致。进一步分析发现,来自研究一的MAXEIG、MAMBAC结果和来自研究二的两个LPA结果相关程度在0.68-0.87之间,肯德尔和谐系数为0.82,表明这四种分类方法的结果有较高的一致性。全部结果都支持自伤青少年中存在病理性自伤和发展性自伤两个异质类别的假设。
研究三至研究五的目的是在分类研究的基础上,根据对发展性自伤和病理性自伤的理论分析,对两类自伤人群的区分特征进行进一步探索和检验。
研究三,采用问卷法检验病理性自伤组、发展性自伤组和无自伤组在自伤的影响因素(早期创伤经验、父母关爱、父母控制、情绪调节困难和情绪反应性)和临床症状(焦虑、抑郁、BPD)上是否存在差异。研究对象同研究一。结果表明,除父母控制外,三组被试在上述变量(除父母控制外)上存在差异。病理性自伤组在早期创伤经验、情绪调节困难和情绪反应性上的得分最高,在父母关爱上得分最低。
研究四和研究五采用实验法分别检验病理性自伤的核心区分特征——高情绪反应性和对社会性线索刺激的高反应敏感性。研究对象来自研究一,随机抽取病理性自伤青少年24人,发展性自伤和无自伤青少年各28人参加实验。两个研究采用同一批研究对象。研究四通过正负性视频诱发实验室情绪,采用自我报告和心率变异为情绪反应性的测量指标。实验假设是：病理性自伤组在观看正/负性视频后报告的正/负性情绪状态水平更高,观看两段视频过程中心率变异的一致性程度更低。结果显示,三组在两段视频观后的自我报告和心率变异指标均不存在统计学差异。
研究五采用面孔表情识别范式,以反应时、准确率和反应偏向为测量指标检验三组被试对三种面孔表情(正性、负性和中性)的识别能力。假设认为,病理性自伤青少年对情绪性表情(正性和负性)更敏感,表现为对高认同度正负情绪表情的识别反应时更短；对低认同度负性表情的识别更困难,表现为准确率更低；对低认同度中性表情有负性反应偏向,表现为以负性表情进行按键反应。结果显示三组被试在实验任务中的表现不存在统计学差异。
研究四和研究五两个实验结果均不支持研究假设。在讨论中对出现所得结果的几种可能原因分别做出了分析。倾向性的看法是,可能在实验方法方面存在问题。
结论：(1)目前学界所研究的自伤青少年,可分为病理性和发展性两个异质的亚类,两个类别分别占全体自伤的10%左右和80%以上。两类自伤可以通过伤害频率与伤害程度的综合指标进行区分。未来对自伤的研究与治疗,应重新精炼自伤的入组标准,或区分两类不同的自伤。(2)两类自伤的核心区分特征需要改进研究设计和方法,再做检验。
In the field of psychology, non-Suicidal Self-Injury (NSSI, or Self-injury, SI) is an intentional and repeated destruction of one's own body tissues without suicidal intentions or purposes, this behavior achieves no acceptance by society, which is not fatal or have low lethality. The nature of NSSI should be a kind of maladaptive coping method, whose core problem is emotional dysregulation. NSSI was thought to be contributed by early traumatic experiences, emotional dysregulation, impulsivity and some biological factors. NSSI correlates with many psychopathological problems or dysphrenia, and the suicidal risk of autolesionists suggests to be much higher compared to normal people (66times). In the recently published DSM-V, NSSI has been classified to be an undefined diagnosed disorder. NSSI is frequently seen among adolescents and young adults compared to older adults, with incidence of more than40%in adolescents in China. So, adolescents' injury should be paid more attention.
In previous studies, we found:(1) different injurers showed different behavioral manifestation;(2) every single factor has finite explanation to NSSI;(3) the incidences in adolescents, young adults, and older adults was lowered successively, which suggests that some adolescent injurers would self-cured in later life. So, authors (the author and her director) of this study hypothesize that there are two types in adolescent injurers, each of them having different behavioral manifestations, psychological meanings and influencing factors. One of the two is nonpathological injury, and with maturation, the injurers will convert to more healthy coping skills instead of self-injury to cope with their problems in life.
On this basis, the authors raised a two-type hypothesis of adolescent injurers:all adolescent injurers could be divided into two types, one is pathological injury, which can be considered a form of psychopathology. The other is developmental injury, which can be considered a normative age-dependent response to the maturity gap that accompanies adolescence, similar to normal crisis by Ericksen. The authors also hypothesized that response sensitivity to social cues stimulus is an important character distinguishing pathological from developmental injury, and pathological injurers are more sensitive to some social stimulus than developmental ones.
The purpose of this paper is to test the two-type hypothesis of adolescent injurers by5studies. Study1and study2aims to examine if there are two heterogeneous categories in adolescents injurers by different statistical methods. Based on the results of study1and study2, study3to study5are to test some important distinguishing characters between the two types injurers.
In study1, we carried out taxometric analysis to examine the construct of adolescent injury by using the self-report instrument Adolescent Self-Injurious Behavior Questionnair in a sample of1343 adolescents from a junior middle school, a junior high school, a reformatory school and a juvenile prison. The sample is mixed, that is, both injurers and no-injurers were included. Mean age is15.77(SD=5.40). Three taxometric procedures were used:MAMBAC, MAXEIG, and L-Mode. Results of MAMBAC and MAXEIG indicates that the structure of adolescents injury is a categorical but not a dimensional, there is a pathological taxon in the behavior. Result of L-Mode were excluded due to poor indicator validity.
In study2, we used latent profile analysis (LPA) to test numbers of injurers' types and their characters with the same sample as study1. Two LPA were carried out, one with17self-injury types as indicators, the other with6indicators including self injury, early experiences, parents'love, parents' control, emotion reactivity and emotion regulation difficulty. The two LPA results can and only can calculate a two-type model. Characters of the two types are consistent with the hypothesis of pathological and developmental injurers. Analysis results of two LPA and MAMBAC, MAXEIG correlates from0.68to0.87, which means the four analysis have good consistence, and adolescent injurers have two heterogeneous types:pathological injurers and developmental injurers.
The purpose of study3is to test the differences on self-report influencing factors and clinical symptoms among two types injurers and no-injurers. Sample is the same with study1. Results showed that pathological injurers got the highest scores on emotion reactivity, emotion regulation difficulty, early experiences, and the lowest scores on parents'love, and no-injurers scored on the opposite. Any two groups have statistically significant differences.
In study4and study5, we carried out two laboratory experiments respectively, to test two important distinguishing characters of pathological injurers:emotion reactivity and response sensitivity to social cues. Subjects were invited randomly from study1, including24pathological injurers,28developmental injurers and28no-injurers. In study4, we induced experiment emotions by two positive and negative videos. Self-report emotion and heart rate variability (HRV) were recorded after videos as indicators of emotion reactivity. Results showed no differences on both self-report and HRV between the three groups.
In study5, we used facial expression (positive, negative and neural) recognition paradigm to examine response sensitivity of pathological injurers. Subjects were asked to response to emotional (positive and negative) expressions, and no response to neutral expressions. Results indicated that the three groups performed no difference on react time, accuracy and response bias. Although the two results of study4and study5didn't support the assumptions, they can't falsificate the theorical hypothesises so far. Later discussion showed that the experimental method should be properly adjusted.
Conclusions:adolescents'self-injury is a two-type structure, one is pathological injury, with a proportion of about10%of all injurious adolescents, and the other is developmental injury, with a proportion of more than80%. The two types can be simply divided by injury. In the future, study and treatments of adolescent injurers should distinguish the two types.
此前对青少年自伤行为的研究一再发现以下现象：(1)自伤在普通青少年中有超出预期的高发生率(14-56%);(2)不同青少年的自伤有着非常不同的行为学表现；(3)任何单一因素对自伤的解释力均十分有限；(4)自伤的发生率在青少年、青年、成年普通人群中依次递减。对于这些令人费解的现象,本文研究者(作者及其导师)猜测,目前研究者所定义并依据定义选择的自伤群体样本可能是异质的；其内部可能存在不同的亚类,不同亚类自伤的行为学表现、心理学意义,以及影响因素不尽相同；而在自伤的亚类中,可能有一个是非病理性自伤,随着年龄的增长,这类自伤者将逐渐转向健康的应对方式,适应不良的自伤行为将自行停止。
以此认识为基础,本文研究者提出一个自伤青少年的分类假说,包括两个核心假设：(1)全体自伤青少年可以分为两大类,一类可称为病理性自伤,其身心基础、发展历史,以及现时的个体-环境关系存在真正的“病理性”原因；另一类可称之为发展性自伤,其身心基础和发展历史可能基本正常,只是现时个体-环境关系存在不适应情况。(2)两类自伤有着不同的发生机制：病理性自伤是一种病理性行为,自伤行为的发生因个体对某些社会性刺激有高反应敏感性的病理特征,表现为只需要微弱的刺激就会引起个体的高情绪反应；发展性自伤是一种情境性行为,自伤行为的发生主要由外部压力环境导致。
本论文工作的基本目的,即是对此理论假说进行探索和检验。作者共做了5项研究,分别从不同角度对该分类假设进行检验。
研究一,目的是检验自伤青少年是否包含一个异质(病理性)的类别。研究方法采用Taxometric分析法的MAXEIG、MAMBAC和L-Model三种程序。分析指标为《青少年自我伤害行为问卷》得分。由于判断群体异质性的参照对象是普通青少年,因此分析样本为包含有自伤和无自伤行为青少年的混合样本,共1343人。分别来自某市一所普通初中(N=450),一所普通高中(N=518),市工读学校(N=43)和未成年犯管教所(N=332),平均年龄15.77岁(SD=5.40)。其中有自伤行为的青少年582人。L-Mode程序由于指标效度过低而导致结果无效。MAXEIG、MAMBAC程序均显示样本包含一个异质的类别。由于分类指标是症状水平(自伤水平),故该异质类别可视为病理性自伤者,其余为非病理性自伤者。
研究二的目的是采用另一种分类研究方法——潜在剖面图分析(Latent Profile Analysis,LPA),检验自伤青少年可能存在的潜在类别数目,以使之与研究一进行对照,同时也检验所选择的若干分类变量是否可以作为区分不同类别自伤青少年的区分特征。研究对象来自研究一,以有自伤行为的574名青少年为样本。研究方法为潜在剖面图分析(LPA)。分别进行两个LPA分析：第一个以测量自伤的17个条目为指标,检验自伤青少年样本中可能包含的类别数；第二个以自伤、早期创伤经验、父母教养态度、父母管教方式、情绪反应性和情绪调节困难等6个变量为分类指标,检验自伤青少年的类别数和和上述变量作为区分特征的有效性。结果显示两个LPA分析均能且仅能分出两个类别。两类自伤的区分特征与分类假说对“病理性自伤”和“发展性自伤”的描述基本一致。进一步分析发现,来自研究一的MAXEIG、MAMBAC结果和来自研究二的两个LPA结果相关程度在0.68-0.87之间,肯德尔和谐系数为0.82,表明这四种分类方法的结果有较高的一致性。全部结果都支持自伤青少年中存在病理性自伤和发展性自伤两个异质类别的假设。
研究三至研究五的目的是在分类研究的基础上,根据对发展性自伤和病理性自伤的理论分析,对两类自伤人群的区分特征进行进一步探索和检验。
研究三,采用问卷法检验病理性自伤组、发展性自伤组和无自伤组在自伤的影响因素(早期创伤经验、父母关爱、父母控制、情绪调节困难和情绪反应性)和临床症状(焦虑、抑郁、BPD)上是否存在差异。研究对象同研究一。结果表明,除父母控制外,三组被试在上述变量(除父母控制外)上存在差异。病理性自伤组在早期创伤经验、情绪调节困难和情绪反应性上的得分最高,在父母关爱上得分最低。
研究四和研究五采用实验法分别检验病理性自伤的核心区分特征——高情绪反应性和对社会性线索刺激的高反应敏感性。研究对象来自研究一,随机抽取病理性自伤青少年24人,发展性自伤和无自伤青少年各28人参加实验。两个研究采用同一批研究对象。研究四通过正负性视频诱发实验室情绪,采用自我报告和心率变异为情绪反应性的测量指标。实验假设是：病理性自伤组在观看正/负性视频后报告的正/负性情绪状态水平更高,观看两段视频过程中心率变异的一致性程度更低。结果显示,三组在两段视频观后的自我报告和心率变异指标均不存在统计学差异。
研究五采用面孔表情识别范式,以反应时、准确率和反应偏向为测量指标检验三组被试对三种面孔表情(正性、负性和中性)的识别能力。假设认为,病理性自伤青少年对情绪性表情(正性和负性)更敏感,表现为对高认同度正负情绪表情的识别反应时更短；对低认同度负性表情的识别更困难,表现为准确率更低；对低认同度中性表情有负性反应偏向,表现为以负性表情进行按键反应。结果显示三组被试在实验任务中的表现不存在统计学差异。
研究四和研究五两个实验结果均不支持研究假设。在讨论中对出现所得结果的几种可能原因分别做出了分析。倾向性的看法是,可能在实验方法方面存在问题。
结论：(1)目前学界所研究的自伤青少年,可分为病理性和发展性两个异质的亚类,两个类别分别占全体自伤的10%左右和80%以上。两类自伤可以通过伤害频率与伤害程度的综合指标进行区分。未来对自伤的研究与治疗,应重新精炼自伤的入组标准,或区分两类不同的自伤。(2)两类自伤的核心区分特征需要改进研究设计和方法,再做检验。
In the field of psychology, non-Suicidal Self-Injury (NSSI, or Self-injury, SI) is an intentional and repeated destruction of one's own body tissues without suicidal intentions or purposes, this behavior achieves no acceptance by society, which is not fatal or have low lethality. The nature of NSSI should be a kind of maladaptive coping method, whose core problem is emotional dysregulation. NSSI was thought to be contributed by early traumatic experiences, emotional dysregulation, impulsivity and some biological factors. NSSI correlates with many psychopathological problems or dysphrenia, and the suicidal risk of autolesionists suggests to be much higher compared to normal people (66times). In the recently published DSM-V, NSSI has been classified to be an undefined diagnosed disorder. NSSI is frequently seen among adolescents and young adults compared to older adults, with incidence of more than40%in adolescents in China. So, adolescents' injury should be paid more attention.
In previous studies, we found:(1) different injurers showed different behavioral manifestation;(2) every single factor has finite explanation to NSSI;(3) the incidences in adolescents, young adults, and older adults was lowered successively, which suggests that some adolescent injurers would self-cured in later life. So, authors (the author and her director) of this study hypothesize that there are two types in adolescent injurers, each of them having different behavioral manifestations, psychological meanings and influencing factors. One of the two is nonpathological injury, and with maturation, the injurers will convert to more healthy coping skills instead of self-injury to cope with their problems in life.
On this basis, the authors raised a two-type hypothesis of adolescent injurers:all adolescent injurers could be divided into two types, one is pathological injury, which can be considered a form of psychopathology. The other is developmental injury, which can be considered a normative age-dependent response to the maturity gap that accompanies adolescence, similar to normal crisis by Ericksen. The authors also hypothesized that response sensitivity to social cues stimulus is an important character distinguishing pathological from developmental injury, and pathological injurers are more sensitive to some social stimulus than developmental ones.
The purpose of this paper is to test the two-type hypothesis of adolescent injurers by5studies. Study1and study2aims to examine if there are two heterogeneous categories in adolescents injurers by different statistical methods. Based on the results of study1and study2, study3to study5are to test some important distinguishing characters between the two types injurers.
In study1, we carried out taxometric analysis to examine the construct of adolescent injury by using the self-report instrument Adolescent Self-Injurious Behavior Questionnair in a sample of1343 adolescents from a junior middle school, a junior high school, a reformatory school and a juvenile prison. The sample is mixed, that is, both injurers and no-injurers were included. Mean age is15.77(SD=5.40). Three taxometric procedures were used:MAMBAC, MAXEIG, and L-Mode. Results of MAMBAC and MAXEIG indicates that the structure of adolescents injury is a categorical but not a dimensional, there is a pathological taxon in the behavior. Result of L-Mode were excluded due to poor indicator validity.
In study2, we used latent profile analysis (LPA) to test numbers of injurers' types and their characters with the same sample as study1. Two LPA were carried out, one with17self-injury types as indicators, the other with6indicators including self injury, early experiences, parents'love, parents' control, emotion reactivity and emotion regulation difficulty. The two LPA results can and only can calculate a two-type model. Characters of the two types are consistent with the hypothesis of pathological and developmental injurers. Analysis results of two LPA and MAMBAC, MAXEIG correlates from0.68to0.87, which means the four analysis have good consistence, and adolescent injurers have two heterogeneous types:pathological injurers and developmental injurers.
The purpose of study3is to test the differences on self-report influencing factors and clinical symptoms among two types injurers and no-injurers. Sample is the same with study1. Results showed that pathological injurers got the highest scores on emotion reactivity, emotion regulation difficulty, early experiences, and the lowest scores on parents'love, and no-injurers scored on the opposite. Any two groups have statistically significant differences.
In study4and study5, we carried out two laboratory experiments respectively, to test two important distinguishing characters of pathological injurers:emotion reactivity and response sensitivity to social cues. Subjects were invited randomly from study1, including24pathological injurers,28developmental injurers and28no-injurers. In study4, we induced experiment emotions by two positive and negative videos. Self-report emotion and heart rate variability (HRV) were recorded after videos as indicators of emotion reactivity. Results showed no differences on both self-report and HRV between the three groups.
In study5, we used facial expression (positive, negative and neural) recognition paradigm to examine response sensitivity of pathological injurers. Subjects were asked to response to emotional (positive and negative) expressions, and no response to neutral expressions. Results indicated that the three groups performed no difference on react time, accuracy and response bias. Although the two results of study4and study5didn't support the assumptions, they can't falsificate the theorical hypothesises so far. Later discussion showed that the experimental method should be properly adjusted.
Conclusions:adolescents'self-injury is a two-type structure, one is pathological injury, with a proportion of about10%of all injurious adolescents, and the other is developmental injury, with a proportion of more than80%. The two types can be simply divided by injury. In the future, study and treatments of adolescent injurers should distinguish the two types.
引文
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