Psychiatry Research 296 (2021) 113672

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Psychiatry Research
journal homepage: www.elsevier.com/locate/psychres

Diagnostic Correlates of Nonsuicidal Self-Injury Disorder among Veterans

with Psychiatric Disorders
Tapan A. Patel a, b, *, Adam J. D. Mann a, d, Shannon M. Blakey a, b, Frances M. Aunon a,
Patrick S. Calhoun a, b, c, d, Jean C. Beckham a, b, c, d, Nathan A. Kimbrel a, b, c, d
a
Durham Veterans Affairs (VA) Health Care System, Durham, NC, USA
b
VA Mid-Atlantic Mental Illness Research, Education and Clinical Center, Durham, NC, USA
c
VA Health Services Research and Development Center of Innovation to Accelerate Discovery and Practice Transformation, Durham, NC, USA
d
Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, USA

A R T I C L E I N F O A B S T R A C T

Keywords: With its recent inclusion in the Diagnostic and Statistical Manual, nonsuicidal self-injury disorder (NSSID) has
Self-harm received limited research attention, especially in samples of military veterans. The present study sought to
Suicide identify diagnostic predictors of NSSID within a veteran sample. Study participants included 124 veterans with at
Borderline personality disorder
least one psychiatric diagnosis. Chi-square tests and t-tests evaluated bivariate associations between NSSID and
Obsessive compulsive disorder
Veterans
twenty diagnostic correlates. Logistic regression models identified psychiatric disorders that were unique cor­
relates of NSSID among veterans. Veterans with lifetime NSSID (n = 59) met criteria for a greater number of
lifetime disorders than veterans with other psychiatric disorders. Bivariate associations were noted between
NSSID and borderline personality disorder, depression, obsessive-compulsive disorder, generalized anxiety dis­
order, and cannabis use disorder. In the logistic regression model, only borderline personality disorder (AOR =
7.67) and obsessive-compulsive disorder (AOR = 3.23) continued to be associated with NSSID. The present study
represents the first examination of the association between NSSID and psychiatric disorders among veterans. The
findings shed light on psychiatric disorders associated with lifetime NSSID in veterans, with special consideration
toward obsessive-compulsive disorder as a risk factor for NSSID.

Introduction
NSSI behaviors are prominent among people with borderline per­
sonality disorder (Gratz et al., 2015), and self-injurious thoughts and
behaviors (including NSSI as well as recurrent suicidal behavior, ges­
tures, and threats) are a symptoms of borderline personality disorder in
DSM-5 (APA, 2013). As a result, many empirical studies of NSSI
behavior have utilized samples of adolescent girls and women with
borderline personality disorder. Moreover, a meta-analysis of risk fac­
tors for NSSI identified cluster B personality disorders (including
borderline personality disorder; weighted OR = 5.93, p < .01), depres­
sion (weighted OR = 1.98, p < .01), and eating disorder pathology
(weighted OR = 1.81, p < .01) as the strongest overall diagnostic pre­
dictors of NSSI (Fox et al., 2015). NSSI has, however, been associated
with a much wider array of psychopathology (Bentley et al, 2015; Briere
& Gil, 1998), including anxiety disorders (Bentley et al., 2015), sub­
stance use disorders (Gratz et al., 2015), and posttraumatic stress
disorder (PTSD; Bentley et al., 2015; Briere & Gil, 1998; Glenn &
Klonsky, 2013; Gratz et al., 2015). For example, Bentley and colleagues
(2015) conducted a meta-analysis of the association between emotional
disorders (i.e., mood and anxiety disorders) and NSSI and found that,
broadly speaking, individuals with an emotional disorder were signifi­
cantly more likely than those without an emotional disorder to engage in
NSSI, OR = 1.75, p < .001. Indeed, with the exception of bipolar dis­
order, OR = 1.05, p = .849, and social anxiety disorder, OR = 1.44, p =
.086, all other mood and anxiety disorders examined in this analysis
were associated with significantly increased risk for NSSI. The emotional
disorders with the largest pooled odds ratios in relation to NSSI included
in this meta-analysis were panic disorder, OR = 2.67, p < .001, PTSD,
OR = 2.06, p < .001, generalized anxiety disorder, OR = 1.94, p < .001,
obsessive-compulsive disorder (OCD), OR = 1.94, p = 0.04, and
depression, OR = 1.90, p < .001.
The vast majority of studies in this area of literature have examined
the relationship between psychiatric disorders and NSSI behaviors rather

* Corresponding author.
E-mail address: tapan.patel3@va.gov (T.A. Patel).

https://doi.org/10.1016/j.psychres.2020.113672
Received 7 July 2020; Accepted 20 December 2020
Available online 28 December 2020
0165-1781/Published by Elsevier B.V.
T.A. Patel et al.
than NSSID per se; however, growing research suggests that NSSID is also
frequently comorbid with other psychiatric disorders. For example,
Kiekens and colleagues (2018) reported that undergraduate students
meeting NSSID criteria were more likely to have multiple psychiatric
disorders, particularly major depressive disorder and alcohol depen­
dence, compared to students without NSSID. Similarly, Gratz and col­
leagues (2015) found that adults with NSSID were more likely to have
co-occurring borderline personality disorder and depression compared
to their counterparts without NSSID. Taken together, prior research
suggests that individuals with NSSID are more likely to meet diagnostic
criteria for multiple psychiatric disorders compared with individuals
without NSSID. In addition, as with NSSI behaviors, borderline per­
sonality disorder and depression are among the most consistent diag­
nostic predictors of NSSID. Thus, it is perhaps not surprising that much
of the research on NSSI and NSSID to date has focused on individuals
with these disorders.
At the same time, there has also been growing recognition in recent
years of the relevance of NSSI to a variety of previously understudied
populations, particularly male veterans with PTSD (e.g., Kimbrel et al.,
2017, 2018). As noted by Kimbrel et al. (2017), this oversight is partly
due to the historical viewpoint that NSSI was much more common
among women than men. Though some studies have found that NSSI
prevalence rates may differ by sex, these studies primarily observe these
findings in clinical samples (Bresin & Schoenloeber, 2015). In contrast,
population-based studies of NSSI have found rates of NSSI do not differ
between males and females (Briere & Gil, 1998; Klonsky et al, 2014).
Moreover, high rates of both PTSD (Fulton et al., 2015) and suicide
(Villatte et al., 2015) among veterans, coupled with research linking
NSSI to PTSD (Sami & Hallaq, 2018) and suicide (Kiekens et al., 2018)
have prompted investigators to study NSSI among veterans. For
instance, Kimbrel and colleagues (2018) recently reported that 82% of
veterans seeking treatment for PTSD (96% of whom were men) reported
a lifetime history of engaging in NSSI. Furthermore, nearly two in three
(64%) reported that they had engaged in one or more forms of NSSI
during the past two weeks. Beyond PTSD, veterans also have higher rates
of other psychiatric disorders (Trivedi et al., 2015; Williamson et al.,
2018), which is likely due in part to the broad effects of combat exposure
on risk for psychiatric symptomatology (Kimbrel et al., 2015). For
example,Kimbrel and colleagues (2015) found that nearly three-fourths
(73.6%) of Iraq/Afghanistan veterans screened positive for one or more
psychiatric conditions, half (51.2%) screened positive for three or more,
and one in three (34.9% or 45/129) screened positive for five or more
psychiatric conditions on a well-validated psychiatric screening mea­
sure. Similarly, Fiedler and colleagues (2006) found that veterans
deployed in the Gulf War had rates of depression and generalized anx­
iety disorder that were approximately double those of men in the gen­
eral population.
Study Objective and Hypotheses
Given the dearth of research on NSSID in general to date, particularly
among veterans, the objective of the present research was to identify
diagnostic predictors of NSSID in a large, well-characterized sample of
veterans. Based on prior research (e.g., Gratz et al., 2015; Kiekens et al.,
2018), we hypothesized that: (H1) veterans with lifetime NSSID would
meet criteria for a significantly greater number of lifetime psychiatric
disorders (excluding NSSID) compared with veteran participants diag­
nosed with other psychiatric disorders (i.e., psychiatric controls). While
prior research has indicated that individuals with NSSID are more likely
than individuals without NSSID to have additional psychiatric disorders,
this work has been limited by the fact that prior studies have not
examined this question among veteran and only one prior study (Gratz
et al., 2015) to our knowledge has utilized psychiatric controls for
comparison. In addition, based on prior meta-analyses of diagnostic
predictors of NSSI behaviors in civilians (e.g., Bentley et al., 2016; Fox
et al., 2015), we further hypothesized that: (H2) borderline personality
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Psychiatry Research 296 (2021) 113672
disorder, depression, PTSD, eating disorders, substance use disorders,
and anxiety disorders would all be associated with NSSID at the bivar­
iate level. Finally, based on the magnitude and consistency of their as­
sociations with NSSI and NSSID in prior research (e.g., Bentley et al.,
2016; Fox et al., 2015; Gratz et al., 2015; Kiekens et al., 2018), we hy­
pothesized that: (H3) borderline personality disorder and depression
would have the strongest bivariate associations with NSSID (Bentley
et al., 2016; Fox et al., 2015; Kimbrel et al., 2018) and would remain
unique predictors of NSSID among veterans with psychiatric disorders in
the multivariable logistic regression model.
Method
Participants and Procedures
Study participants included 124 veterans who consented to partici­
pate in a VA-sponsored study (#I01CX001486) aimed at identifying the
functional consequences of NSSID in veterans relative to other psychi­
atric conditions. The study received approval from the Durham Veterans
Affairs Health Care System (VAHCS) Institutional Review Board prior to
data collection. Participants were primarily recruited through letters
and calls to potential participants who: (1) had previously sought care
for PTSD at the Durham VAHCS; (2) had previously agreed to have their
names included in one or more research recruitment databases; or (3)
were referred to the study by clinicians at the Durham VAHCS. All
participants were initially screened by phone.
Note that veterans with PTSD were specifically targeted because: (1)
NSSI is substantially underreported among veterans (Kimbrel et al.,
2017); and (2) prior research suggests that veterans seeking treatment
for PTSD have particularly high rates of NSSI (e.g., Kimbrel et al., 2018).
Participants that appeared to meet basic eligibility criteria were then
invited for an in-person screening to determine final study eligibility. To
be eligible to participate in the study, participants had to have served in
the U.S. military, be over the age of 18, be willing and able to complete
the study and procedures, and had to have one or more current psy­
chiatric disorders; however, participants with diagnoses of bipolar dis­
order, schizophrenia, and/or schizoaffective disorder were excluded
from the study, as functional disability in relation to NSSID was a pri­
mary outcome and there was concern that inclusion of participants with
severe mental illness in the study could potentially confound the asso­
ciation between NSSID and functioning, given the robust association
between severe mental illness and functional disability.
Veterans with NSSID and women veterans were oversampled
through the screening process to ensure sufficient representation in the
statistical analyses. As a result, nearly half of the sample (n = 59; 47.6%)
met full diagnostic criteria for a lifetime diagnosis of NSSID, and a third
of the sample (n = 41; 33.1%) met criteria for current diagnosis of
NSSID. The rest of the sample (n = 65; 52.4%) comprised veterans who
met criteria for one or more lifetime psychiatric disorders but did not
meet full criteria for lifetime NSSID. Note that 35.4% (n = 23) of the
veterans who did not meet lifetime criteria for NSSID did report a history
of lifetime NSSI behavior; however, their NSSI symptoms were insuffi­
cient to meet full criteria for lifetime NSSID. See Table 1 for a list of NSSI
behaviors endorsed by the n = 89 participants with lifetime NSSI.
Approximately one-fourth of the sample identified as women (n =
32; 25.8%). With respect to race, 51.6% (n = 64) veterans identified as
Black, 41.9% (n=52) identified as White, 4.0% (n = 5) identified as
Other or else declined to answer, 1.6% (n = 2) identified as more than
one race, and 0.8% (n = 1) of the sample identified as Asian. With
respect to ethnicity, two veterans (1.6%) identified as Hispanic. The
mean age of the sample was 48.7 years (SD = 13.0; range: 23-77).
Measures
The Structured Clinician Interview for DSM-5 (SCID-5; First et al.,
2015) was used to assess mood disorders, anxiety disorders, and
T.A. Patel et al. Psychiatry Research 296 (2021) 113672

Table 1
Frequency of NSSI Behaviors Among Veterans with Lifetime History of NSSI (n = 82)
NSSI Behavior n (%) Lifetime NSSI n (%) Lifetime NSSI Disorder Х2 φ p

Cutting 5.48 0.26 .019

No 23 (100.0%) 47 (79.7%)
Yes 0 (0.0%) 12 (20.3%)
Burning with Cigarette 2.08 0.16 .150
No 23 (100.0%) 54 (91.5%)
Yes 0 (0.0%) 5 (8.5%)
Burning with Lighter or Match 1.64 0.14 .200
No 23 (100.0%) 55 (93.2%)
Yes 0 (0.0%) 4 (6.8%)
Carving words 0.39 0.07 .530
No 23 (100.0%) 58 (98.3%)
Yes 0 (0.0%) 1 (1.7%)
Carving pictures or designs 1.67 0.14 .196
No 23 (100.0%) 55 (93.2%)
Yes 0 (0.0%) 4 (6.8%)
Scratching 4.80 0.57 .028
No 21 (91.3%) 40 (67.8%)
Yes 2 (8.7%) 19 (32.2%)
Biting 2.65 0.18 .104
No 20 (87.0%) 41 (69.5%)
Yes 3 (13.0%) 18 (30.5%)
Rubbing sandpaper 0.04 0.02 .836
No 22 (95.7%) 57 (96.6%)
Yes 1 (4.3%) 2 (3.4%)
Sticking Sharp Objects 4.68 0.24 .031
No 22 (95.7%) 44 (74.6%)
Yes 1 (4.3%) 15 (25.4%)
Rubbing Glass 0.40 0.07 .530
No 23 (100.0%) 58 (98.3%)
Yes 0 (0.0%) 1 (1.7%)
Banging Head 4.80 0.57 .028
No 21 (91.3%) 40 (67.8%)
Yes 2 (8.7%) 19 (32.2%)
Punching Self 3.57 0.21 .059
No 20 (87.0%) 39 (66.1%)
Yes 3 (13.0%) 20 (33.9%)
Preventing Wounds from Healing 1.97 0.15 .160
No 21 (91.3%) 46 (78.0%)
Yes 2 (8.7%) 13 (22.0%)
Punching Walls 6.41 0.28 .011
No 14 (60.9%) 18 (30.5%)
Yes 9 (39.1%) 41 (69.5%)

Note. NSSI = Nonsuicidal self-injury; Degrees of freedom for all tests = 1; φ = Phi effect size coefficient, where 0.1, 0.3, and 0.5 signify effects of small, medium, and
large magnitude, respectively.

substance-use disorders. It has demonstrated excellent overall internal
consistency and test-retest reliability in previous work (Shankman et al.,
2018). Master’s level clinicians administered the SCID-5 under the su­
pervision of licensed clinical psychologists. Reliability among in­
terviewers for SCID-based diagnoses was excellent (Fleiss’ kappa = 0.92
for lifetime psychiatric disorders on fidelity training videos). The Clin­
ician-Administered Nonsuicidal Self-injury Disorder Index (CANDI; Gratz
et al., 2015) was used to diagnose NSSID. The CANDI is a diagnostic
interview for NSSID that has demonstrated good interrater reliability (ᴋ
= .83) and adequate internal consistency (α = .71) in prior research
(Gratz et al., 2015). The Deliberate Self-Harm Inventory (DSHI), which
lists various NSSI behaviors (e. g., cutting, burning, carving in skin,
scratching, biting, acid or cleaner burns, sticking sharp objects, banging
head, and punching walls or objects) and has the participant rate if they
have engaged in the behavior and the frequency in the past year, was
used as part of the CANDI interview. Master’s level clinicians adminis­
tered the CANDI under the supervision of licensed clinical psychologists.
Because NSSID was the focus of the present study and is currently listed
as condition for further study in DSM-5, each CANDI was reviewed and
discussed in diagnostic review groups led by a licensed clinical psy­
chologist until diagnostic consensus was reached.
Data Analysis Plan
All analyses were conducted with SPSS Version 25. A total number of
psychiatric disorders sum variable was created by summing all twenty
diagnostic predictors considered in the analyses (see Table 2). Note that
NSSID was excluded from the calculation of this score. Chi-square tests
and t-tests were then used to evaluate bivariate associations between
NSSID, demographic characteristics, and psychiatric disorders. Logistic
regression was used to identify psychiatric diagnostic predictors of
NSSID in veterans.
Results
Sex, race, and ethnicity were unrelated to NSSID at the bivariate
level (all p’s ≥ .14); however, a significant association was observed
between age and NSSID, such that veterans who met lifetime criteria for
NSSID (M = 45.9, SD = 12.4) were significantly younger than veterans
who did not [M = 51.3, SD = 12.9, t(122) = 2.35, p = 0.02]. Notably, the
total number of psychiatric disorders variable was normally distributed
in the present sample (M = 4.4, SD = 1.8, range: 1-10, skewness = 0.22,
kurtosis = 0.43). Moreover, veterans with NSSID (n = 59, M = 5.3, SD =
1.9) met criteria for a significantly greater number of disorders than
veterans with other psychiatric disorders [n= 65, M = 3.5, SD = 1.2, t
(122) = 2.35, p = 0.02]. As can be seen in Fig. 1, a clear linear

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T.A. Patel et al. Psychiatry Research 296 (2021) 113672

Table 2
Bivariate Associations between Demographic Variables, Psychiatric Diagnoses, and Lifetime Nonsuicidal Self-Injury Disorder among Veterans with Psychiatric Dis­
orders (N=124).
Variable % Lifetime NSSI Disorder (n¼59) % Without Lifetime NSSI Disorder (n¼65) Test Statistic p-value

Age t(122) ¼ 2.35 0.02

Biological Sex at Birth Х 2(1) = 1.30 0.25

Male Sex at Birth 69.5% 78.5%
Female Sex at Birth 30.5% 21.5%

Race Х 2(4) = 1.67 0.80

Black 52.5% 50.8%
White 39.0% 44.6%
Other/Unknown 5.1% 3.1%
More than One Race 1.7% 1.5%
Asian 1.7% 0.0%

Ethnicity Х 2(1) = 2.24 0.14

Non-Hispanic 96.6% 100.0%
Hispanic 3.4% 0.0%

Psychiatric Disorders (Lifetime)

Borderline Personality Disorder 66.1% 15.4% Х2(1) ¼ 33.28 <0.001
Posttraumatic Stress Disorder 96.6% 89.2% Х 2(1) = 2.50 0.11
Major Depressive Disorder 94.9% 78.5% Х2(1) ¼ 7.08 0.008
Obsessive-Compulsive Disorder 50.8% 21.5% Х2(1) ¼ 11.61 0.001
Panic Disorder 27.1% 15.4% Х 2(1) = 2.57 0.11
Social Anxiety Disorder 16.9% 6.2% Х 2(1) = 3.60 0.06
Specific Phobia 3.4% 1.5% Х 2(1) = 0.45 0.50
Generalized Anxiety Disorder 27.1% 10.8% Х2(1) ¼ 5.47 0.02
Alcohol Use Disorder 71.2% 70.8% Х 2(1) = 0.003 0.96
Sedative Use Disorder 5.1% 1.5% Х 2(1) = 1.25 0.26
Cannabis Use Disorder 22.0% 9.2% Х2(1) ¼ 3.91 0.048
Stimulant Use Disorder 18.6% 16.9% Х 2(1) = 0.06 0.80
Opioid Use Disorder 10.2% 3.1% Х 2(1) = 2.58 0.11
Inhalant Use Disorder 0.0% 1.5% Х 2(1) = 0.92 0.34
Hallucinogen Use Disorder 0.0% 1.5% Х 2(1) = 0.92 0.34
Other Drug Use Disorder 1.7% 0.0% Х 2(1) = 1.11 0.29
Anorexia Nervosa 1.7% 0.0% Х 2(1) = 1.11 0.29
Bulimia Nervosa 3.4% 0.0% Х 2(1) = 2.24 0.14
Binge Eating Disorder 8.5% 6.2% Х 2(1) = 0.25 0.62
Any Eating Disorder 18.6% 7.7% Х 2(1) = 3.30 0.07
Any Drug Use Disorder 35.6% 26.2% Х 2(1) = 1.30 0.26

Note: Variables with bivariate associations significant at p < 0.05 are shown in bold.

relationship between number of disorders and rate of NSSID was
observed. Consistent with H1, a logistic regression model [Table 2:
model 1; Х 2(1) = 35.99, p < 0.001, Nagelkerke pseudo R2 = 0.34,
overall classification rate = 72.6%; f2 = 0.59, large effect size] found
that each additional psychiatric diagnosis more than doubled veterans’
odds of meeting criteria for NSSID, OR = 2.13, p < 0.001.
Next, we examined bivariate associations between NSSID and psy­
chiatric disorders. Consistent with H3, we observed statistically signifi­
cant bivariate associations between lifetime NSSID and borderline
personality disorder, Х 2(1) = 33.28, p < 0.001, and depression, Х 2(1) =
7.08, p = 0.008, such that veterans with these conditions were signifi­
cantly more likely to also meet criteria for NSSID. We observed similar
statistically significant associations between NSSID and OCD, Х 2(1) =
11.61, p = 0.001, generalized anxiety disorder, Х 2(1) = 5.47, p = 0.02,
and cannabis use disorder, Х 2(1) = 3.91, p = 0.048, such that veterans
with these disorders were also more likely to meet diagnostic criteria for
NSSID (Fig. 2). However, in contrast with H2, we did not observe sig­
nificant bivariate associations between NSSID and PTSD, panic disorder,
social anxiety disorder, specific phobia, alcohol use disorder, sedative
use disorder, stimulant use disorder, opioid use disorder, inhalant use
disorder, hallucinogen use disorder, other use disorder, anorexia nerv­
osa, bulimia nervosa, binge eating disorder, and other eating disorder
(all p’s > 0.05), though it should be noted that most of the drug use and
eating disorders had too few cases to analyze individually in a mean­
ingful way. Accordingly, we also constructed a composite variable for
any drug use disorder and for any eating disorder; however, as can be
seen in Table 2, these composite variables were also unrelated to NSSID.
The demographic variables and psychiatric diagnoses observed to
have significant bivariate associations with NSSID at α =0.05 (i.e., age,
borderline personality disorder, depression, OCD, generalized anxiety
disorder, and cannabis use disorder) were subsequently entered into a
logistic regression model (model 2; simultaneous entry) in order to
identify variables that uniquely contributed to the prediction of NSSID
among veterans with psychiatric disorders. As can be seen in Table 3,
the overall model was statistically significant, Х 2(6) = 50.88, p < 0.001,
Nagelkerke pseudo R2 = 0.45, overall correct classification rate =
75.8%, f2 = 0.82, large effect size; however, among the six variables
considered, only borderline personality disorder, adjusted odds ratio
(AOR) = 7.67, p < 0.001, and OCD, AOR = 3.23, p = 0.02, continued to
have statistically significant associations with NSSID in this model.
Accordingly, a third logistic regression model was conducted in which
backward stepwise selection was used to systematically eliminate non-
significant (i.e., p ≥ 0.05) predictors from the model. As can be seen
in Table 3, age was removed from the model in step 2, generalized
anxiety disorder was removed in step 3, cannabis use disorder was
removed in step 4, and depression was removed in step 5, leaving only
borderline personality disorder, AOR = 10.1, p < 0.001, and OCD, AOR
= 3.4, p = 0.008, in the final model. The final, more parsimonious model
(i.e., step 5) resulting from the backwards stepwise selection procedure
remained statistically significant, Х 2(2) = 42.43, p < 0.001, Nagelkerke
pseudo R2 = 0.39, f2 = 0.64, large effect size. Moreover, the overall
classification rate (75.8%) for this more parsimonious model containing
only borderline personality disorder and OCD was identical to the
overall classification rate for model 2 (i.e., 75.8%; simultaneous entry

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T.A. Patel et al. Psychiatry Research 296 (2021) 113672

Fig. 1. Rates of NSSID as a Function of Total Number of Psychiatric Disorders (N=124).

Fig. 2. Rates of NSSID by Diagnosis among Veterans with Psychiatric Disorders (N=124).

model) and higher than that of model 1 (72.6%; total number of psy­
chiatric disorders model), suggesting that borderline personality disor­
der and obsessive-compulsive are likely responsible for much of the
robust association observed between total number of psychiatric disor­
ders and lifetime NSSID (Fig. 1)
Discussion
Though previous studies have explored the link between psychiatric
disorders and NSSI behaviors broadly (e.g., Bentley et al., 2016; Fox
et al., 205), the vast majority of research in this area has focused on
civilian populations and NSSI behaviors (as opposed to NSSID). To our
knowledge, the present research represents the first and only study to
examine the association between NSSID and a broad array of psychiatric
disorders in a sample of veterans.
Consistent with our first hypothesis, we found that veterans with
NSSID met criteria for a significantly greater number of disorders than
veterans with other psychiatric disorders. Indeed, on average, we found

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T.A. Patel et al. Psychiatry Research 296 (2021) 113672

Table 3
Summary of Logistic Regression Models Predicting Lifetime NSSI Disorder (N=124).
Model 1: Total number of psychiatric disorders as a predictor of lifetime NSSI Disorder (Nagelkerke R2 ¼ 0.37)
Variable Name B SE OR 95% CI p-value

Total Number of Psychiatric Disorders 0.74 0.15 2.1 1.56 - 2.84 < 0.001
Age -0.03 0.02 0.97 0.94 - 1.00 0.048
Constant -1.68 1.04 0.19 0.11

Model 2: All variables with significant bivariate associations with lifetime NSSI Disorder (Nagelkerke R2 ¼ 0.45)
Variable Name B SE OR 95% CI p-value

Borderline Personality Disorder 2.04 0.48 7.67 2.98 - 19.7 < 0.001
Obsessive-Compulsive Disorder 1.17 0.47 3.23 1.28 - 8.16 0.01
Major Depressive Disorder 1.32 0.75 3.74 0.87 - 16.1 0.08
Cannabis Use Disorder 0.89 0.67 2.43 0.66 - 8.96 0.18
Generalized Anxiety Disorder 0.75 0.62 2.12 0.63 - 7.09 0.22
Age -0.02 0.02 0.98 0.95 - 1.02 0.28
Constant -1.75 1.21 0.17 0.15

Model 3: Backward stepwise selection model (Step 5 Nagelkerke Pseudo R2 ¼ 0.39)

Variable Name B SE OR 95% CI p-value

Step 1 Borderline Personality Disorder 2.04 0.48 7.67 2.98 - 19.7 < 0.001
Obsessive-Compulsive Disorder 1.17 0.47 3.23 1.28 - 8.16 0.01
Major Depressive Disorder 1.32 0.75 3.74 0.87 - 16.1 0.08
Cannabis Use Disorder 0.89 0.67 2.43 0.66 - 8.96 0.18
Generalized Anxiety Disorder 0.75 0.62 2.12 0.63 - 7.09 0.22
Age -0.02 0.02 0.98 0.95 - 1.02 0.28
Constant -1.75 1.21 0.17 0.15
Step 2 Borderline Personality Disorder 2.14 0.47 8.50 3.36 - 21.5 < 0.001
Obsessive-Compulsive Disorder 1.16 0.48 3.18 1.25 - 8.06 0.02
Major Depressive Disorder 1.39 0.75 4.03 0.92 - 17.6 0.06
Cannabis Use Disorder 0.85 0.65 2.34 0.66 - 8.30 0.19
Generalized Anxiety Disorder 0.77 0.62 2.17 0.65 - 7.28 0.21
Constant -2.81 0.78 0.06 < 0.001
Step 3 Borderline Personality Disorder 2.24 0.47 9.35 3.73 - 23.4 < 0.001
Obsessive-Compulsive Disorder 1.2 0.47 3.31 1.31 - 8.33 0.01
Major Depressive Disorder 1.24 0.72 3.45 0.84 - 14.2 0.09
Cannabis Use Disorder 0.95 0.64 2.59 0.73 - 9.14 0.14
Constant -2.6 0.73 0.08 < 0.001
Step 4 Borderline Personality Disorder 2.25 0.46 9.49 3.83 - 23.5 < 0.001
Obsessive-Compulsive Disorder 1.2 0.47 3.32 1.33 - 8.29 0.01
Major Depressive Disorder 1.24 0.72 3.45 0.84 - 14.2 0.09
Constant -2.47 0.72 0.09 < 0.001
Step 5 Borderline Personality Disorder 2.32 0.46 10.1 4.15 - 24.7 < 0.001
Obsessive-Compulsive Disorder 1.22 0.46 3.4 1.38 - 8.31 0.008
Constant -1.42 0.32 0.24 < 0.001

that veterans with NSSID met full diagnostic criteria for five psychiatric
disorders over the course of their lifetimes. Remarkably, 100% of the 17
veterans who met criteria for seven or more psychiatric disorders in this
study also met criteria for NSSID (Fig. 1). Moreover, each additional
disorder more than doubled participants’ odds of meeting criteria for
NSSID.
Our second hypothesis was only partially supported. As expected, we
did observe statistically significant bivariate associations between
NSSID and depression, OCD, generalized anxiety disorder, and cannabis
use disorder, such that veterans with these disorders were also more
likely to meet diagnostic criteria for NSSID; however, we did not observe
the expected association between NSSID and PTSD. This finding is likely
due to the large number of veterans in the sample with PTSD (n = 115).
NSSID was also unrelated to the majority of anxiety disorders, substance
use disorders, and eating disorders considered. Given the robust asso­
ciations identified between many of these disorders and NSSID in ci­
vilians, we were surprised that so few of these conditions were
associated with NSSID. In some cases (e.g., specific drug use disorders
and eating disorders), there were too few cases to meaningfully examine
these associations; however, even when we grouped drug use disorders
and eating disorders together, we failed to find significant associations
between these classes of disorders and NSSID in this sample of veterans
(all p’s > 0.05).
Finally, consistent with our third hypothesis, we found that border­
line personality disorder was the psychiatric diagnosis most strongly
associated with NSSID at both the bivariate and multivariate level.
Depression was also associated with NSSID at the bivariate level; how­
ever, it was not selected for inclusion in the final step of the stepwise
regression model. Instead, OCD was selected for inclusion in the final
regression model along with borderline personality disorder. Notably,
this final model had a similar overall classification rate as the simulta­
neous regression model that included all six of the variables that had
significant bivariate associations with NSSID (i.e., model 2) and a better
classification rate than the model that utilized total number of disorders
(i.e. model 1), which suggests that borderline personality disorder and
OCD were largely responsible for the robust association observed be­
tween number of psychiatric disorders and lifetime NSSID observed in
the present study (Fig. 1).
While unexpected, the strong association between OCD and NSSID
observed in the present study is in many ways consistent with Bentley
and colleagues’ (2015) meta-analysis of the relationship between NSSI
and emotional disorders. For instance, of the eight different emotional
disorders considered in this meta-analysis, the least studied disorder in
relation to NSSI was OCD, which had only nine effect sizes in the liter­
ature at the time of the meta-analysis. However, despite the relatively
limited amount of attention given to the association between OCD and
NSSI behaviors, Bentley et al. (2015) found that OCD had the third
largest meta-analytic association with NSSI, OR = 1.94, p = .036,
ranking behind only panic disorder, OR = 2.67, p<.001, and PTSD, OR
= 2.06, p < .001. OCD’s meta-analytic odds ratio was similar to the
effect size of depression, OR = 1.90, p < .001, one of the top two
diagnostic predictors of NSSI identified by Fox et al. (2015).

6
T.A. Patel et al.
Strengths of the present study include our use of structured in­
terviews to systematically diagnose a broad array of psychiatric disor­
ders as well as an analytical approach that allowed us to examine unique
contributions of each disorder to the prediction of NSSID; however, it is
likely that these same strengths are at least partly responsible for our
failure to find support for the hypothesis that depression would be a
unique predictor of NSSID among veterans. As noted above, depression
had a significant association with NSSID at the bivariate level but failed
to attain statistical significance in the simultaneous logistic regression
model. A follow-up analysis in which we excluded borderline person­
ality disorder from a simultaneous logistic regression model similar to
model 2 resulted in OCD, OR = 3.61, p = .003, depression, OR = 5.59, p
= 0.02, and age, OR = 0.97, p = .038, all remaining statistically sig­
nificant predictors of NSSID (data not shown; cannabis use disorder, OR
= 2.62, p = .11, and generalized anxiety disorder, OR = 2.86, p = .06,
remained non-significant predictors in this model). Thus, it is likely that
the high rate of co-occurrence between borderline personality disorder,
depression, and NSSID resulted in the model selecting borderline per­
sonality disorder over depression. For example, the rate of NSSID was
much higher among individuals diagnosed with borderline personality
disorder than it was among individuals diagnosed with depression
(79.6% vs. 52.3%). Moreover, 93.9% of veterans with borderline per­
sonality disorder in the present study also met criteria for depression. In
contrast, fewer than half of veterans with borderline personality disor­
der in the present study met criteria for OCD (46.9%). Thus, the robust
association between NSSID and OCD in the present study likely repre­
sented unique variance in the prediction of NSSID, whereas the associ­
ation between depression and NSSID was largely accounted for by
borderline personality disorder.
Clinical Implications
There are a number of important clinical implications that emerge
from the present study. First, the present study adds to the literature on
NSSI in veterans by demonstrating for the first time that veterans with
NSSID are likely to be highly complex and challenging patients to treat,
as veterans with NSSID were found to meet full diagnostic criteria for
five additional psychiatric disorders, on average. As has been noted
previously (e.g., Kimbrel et al., 2018), NSSI and NSSID are frequently
overlooked conditions in veterans, despite the fact that NSSI is likely the
single strongest prospective predictor of suicide attempts identified to
date (Franklin et al, 2017) and NSSID is associated with substantial
distress and impairment (Gratz et al., 2015). Similarly, despite the high
levels of distress and impairment associated with both borderline per­
sonality disorder (Gratz et al., 2015) and OCD (McIngvale et al., 2019),
both of these conditions are likely to be underdiagnosed among veterans
(Barrera et al., 2019; Cunningham et al., 2019). For example, Cun­
ningham et al. (2019) recently observed that nearly one in four (23.5%)
male veterans seeking treatment for PTSD screened positive for severe
borderline personality features. This same study found that veterans
with PTSD, NSSI, and severe borderline personality features were
significantly more likely to report suicidal ideation compared with
veterans with PTSD only (OR = 5.68).
Studies utilizing structured diagnostic interviews to estimate the 12-
month prevalence of OCD among veterans suggest that the rate of OCD
may be substantially higher than the 12-month estimates observed
among civilians in community settings (e.g., 1.2%; Barrera et al., 2019;
McIngvale et al., 2019). Moreover, Barrera and colleagues (2019) have
argued that OCD is often underdiagnosed in the veteran population due
to the complexity of the disorder, lack of knowledge by providers, and
attribution of symptoms to PTSD, suggesting that the true prevalence of
OCD may be much higher than the estimates that have been previously
reported. It could also be argued that veterans may be especially prone to
engage in repetitive behaviors meant to reduce distress and gain control
over their environment due to military training learning histories and/or
comorbid disorders associated with increased need for control and
7
Psychiatry Research 296 (2021) 113672
decreased tolerance for unpleasant emotions (Tuerk et al., 2011). Future
research investigating the motivations for NSSI behaviors among vet­
erans with OCD would help to understand, assess, and target NSSID in
this population. For example, substantial research indicates that people
with OCD have difficulty tolerating aversive internal experiences (e.g.,
unpleasant emotions, intrusive thoughts), which might result in per­
forming compulsions and other repetitive behaviors to minimize or
escape their unpleasant internal states (Robinson & Freeston, 2014). It is
therefore possible that there may be a subtype of people with OCD who
frequently turn to NSSI to regulate or better control their aversive in­
ternal experiences (Starcevic et al., 2011).
Study Limitations and Future Directions
The present research had several limitations which should be
considered when interpreting these findings. First, this study was cross-
sectional in nature, which precludes us from being able to determine if
some disorders precede the occurrence of other disorders. Thus, we are
unable to determine if borderline personality disorder and OCD typically
precede the onset of NSSID or, if instead, NSSID typically precedes the
onset of these disorders. Second, the sample was composed entirely of
veterans with psychiatric disorders, the vast majority of whom had
either PTSD or depression but excluded those with severe mental illness.
Thus, the degree to which the present findings might generalize to other
samples of veterans and civilians is not known. Third, the sample was
relatively small and did not allow for more refined analytical
approaches.
Despite these limitations, these findings have important implications
for both future research and clinical practice. Future research could
build on the present study’s limitations and focus on discovering why
OCD and NSSID co-occur. It is important to understand the mechanism
of how and why these two disorders are related. Furthermore, the
findings of this study provide broader implications to the NSSID body of
research. It will be important in future research in NSSID to assess for
OCD in order to further explore whether OCD is a risk factor for
engaging in NSSID. Additionally, in future research, it would be helpful
to investigate the reason for this association and how it affects the
severity of the individual diagnoses. Though the findings from the pre­
sent study cannot be generalized to the general population, it does
provide specific implications for veterans. The study results suggest that
it would be useful in future research with veterans to assess for NSSI
behaviors and NSSID to further identify risk factors and determine
clinical implications. Mental health and medical practitioners need to be
aware of the risk of veterans with OCD having co-occurring NSSID. Both
phenomena can be debilitating and having both could prove to be
difficult given there are currently no current evidence-based treatments
for NSSI in the veteran population. When working with veterans, it will
be important to assess for both NSSI and OCD to maximize treatment
outcomes. The results suggest that the highest levels of psychiatric co­
morbidity are accompanied by NSSID. Developing and evaluating
effective treatments for NSSID will be important in addressing the
mental health needs of veterans who have the highest prevalence of
multiple psychiatric disorders.
CRediT authorship contribution statement
Tapan A. Patel: Conceptualization, Methodology, Formal analysis,
Writing - original draft, Writing - review & editing, Investigation. Adam
J. D. Mann: Writing - original draft, Writing - review & editing. Shan­
non M. Blakey: Conceptualization, Writing - original draft, Writing -
review & editing. Frances M. Aunon: Writing - review & editing. Pat­
rick S. Calhoun: Funding acquisition, Supervision. Jean C. Beckham:
Funding acquisition, Supervision. Nathan A. Kimbrel: Conceptualiza­
tion, Methodology, Writing - review & editing, Formal analysis, Funding
acquisition, Supervision, Visualization, Project administration.
T.A. Patel et al.
Declaration of Competing Interest
The views expressed in this article are those of the authors and do not
necessarily reflect the position or policy of the United States Govern­
ment or Department of Veterans Affairs (VA). The authors have no other
conflicts of interest to disclose.
Role of Funding source
Funding: This research was supported by a Merit Award to Dr.
Kimbrel from the Clinical Sciences Research and Development Service of
the Department of Veterans Affairs’ Office of Research and Development
(#I01CX001486). Dr. Blakey was supported by the VA Office of Aca­
demic Affiliations Advanced Fellowship in Mental Illness Research and
Treatment. Dr. Beckham was funded by a Senior Research Career Sci­
entist award from VA Clinical Sciences Research and Development
(IK6BX00377).
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