Inventory of Statements About Self-Injury

INVENTORY OF STATEMENTS ABOUT SELF-INJURY (ISAS) – SECTION I. BEHAVIORS
This questionnaire asks about a variety of self-harm behaviors. Please only endorse a behavior if you have done it intentionally (ie, on purpose) and without suicidal intent (ie, not for suicidal reasons).
1. Please estimate the number of times in your life you have intentionally (ie, on purpose) performed each type of nonsuicidal self-harm (eg, 0, 10, 100, 500):
Cutting		____	Severe scratching		____
Biting		____	Banging or hitting self		____
Burning		____	Interfering with wound healing (eg, picking scabs)		____
Carving		____	Rubbing skin against rough surface		____
Pinching		____	Sticking self with needles		____
Pulling hair		____	Swallowing dangerous substances		____
Other _______________		____
Important: If you have performed one or more of the behaviors listed above, please complete the final part of this questionnaire. If you have not performed any of the behaviors listed above, you are done with this particular questionnaire and should continue to the next.
2. If you feel that you have a main form of self-harm, please circle the behavior(s) on the first page above that you consider to be your main form of self-harm.

3. At what age did you:
First harm yourself?		____________	Most recently harm yourself? (approximate date – month/date/year)		____________
4. Do you experience physical pain during self-harm?
Please circle a choice:			YES	SOMETIMES	NO
5. When you self-harm, are you alone?
Please circle a choice:			YES	SOMETIMES	NO
6. Typically, how much time elapses from the time you have the urge to self-harm until you act on the urge?
Please circle a choice:
<1 hour	1 to 3 hours	3 to 6 hours	6 to 12 hours	12 to 24 hours	>1 day
7. Do/did you want to stop self-harming?
Please circle a choice:				YES	NO
INVENTORY OF STATEMENTS ABOUT SELF-INJURY (ISAS) – SECTION II. FUNCTIONS
Name:_______________
Date:________________
Instructions This inventory was written to help us better understand the experience of nonsuicidal self-harm. Below is a list of statements that may or may not be relevant to your experience of self-harm. Please identify the statements that are most relevant for you: Circle 0 if the statement not relevant for you at all Circle 1 if the statement is somewhat relevant for you Circle 2 if the statement is very relevant for you
"When I self-harm, I am ...			Response
... calming myself down			0	1	2
... creating a boundary between myself and others			0	1	2
... punishing myself			0	1	2
... giving myself a way to care for myself (by attending to the wound)			0	1	2
... causing pain so I will stop feeling numb			0	1	2
... avoiding the impulse to attempt suicide			0	1	2
... doing something to generate excitement or exhilaration			0	1	2
... bonding with peers			0	1	2
... letting others know the extent of my emotional pain			0	1	2
... seeing if I can stand the pain			0	1	2
... creating a physical sign that I feel awful			0	1	2
... getting back at someone			0	1	2
... ensuring that I am self-sufficient			0	1	2
... releasing emotional pressure that has built up inside of me			0	1	2
... demonstrating that I am separate from other people			0	1	2
... expressing anger towards myself for being worthless or stupid			0	1	2
... creating a physical injury that is easier to care for than my emotional distress			0	1	2
... trying to feel something (as opposed to nothing) even if it is physical pain			0	1	2
... responding to suicidal thoughts without actually attempting suicide			0	1	2
... entertaining myself or others by doing something extreme			0	1	2
... fitting in with others			0	1	2
... seeking care or help from others			0	1	2
... demonstrating I am tough or strong			0	1	2
... proving to myself that my emotional pain is real			0	1	2
... getting revenge against others			0	1	2
... demonstrating that I do not need to rely on others for help			0	1	2
... reducing anxiety, frustration, anger, or other overwhelming emotions			0	1	2
... establishing a barrier between myself and others			0	1	2
... reacting to feeling unhappy with myself or disgusted with myself			0	1	2
... allowing myself to focus on treating the injury, which can be gratifying or satisfying			0	1	2
... making sure I am still alive when I don't feel real			0	1	2
... putting a stop to suicidal thoughts			0	1	2
... pushing my limits in a manner akin to skydiving or other extreme activities			0	1	2
... creating a sign of friendship or kinship with friends or loved ones			0	1	2
... keeping a loved one from leaving or abandoning me			0	1	2
... proving I can take the physical pain			0	1	2
... signifying the emotional distress I'm experiencing			0	1	2
... trying to hurt someone close to me			0	1	2
... establishing that I am autonomous/independent			0	1	2
(Optional) In the space below, please list any statements that you feel would be more accurate for you than the ones listed above:

(Optional) In the space below, please list any statements you feel should be added to the above list, even if they do not necessarily apply to you:

ITEMS COMPRISING EACH OF 13 FUNCTIONS SCALES
Affect regulation – 1, 14, 27
Interpersonal boundaries – 2, 15, 28
Self-punishment – 3, 16, 29
Self-care – 4, 17, 30
Anti-dissociation/feeling-generation – 5, 18, 31
Anti-suicide – 6, 19, 32
Sensation-seeking – 7, 20, 33
Peer-bonding – 8, 21, 34
Interpersonal influence – 9, 22, 35
Toughness – 10, 23, 36
Marking distress – 11, 24, 37
Revenge – 12, 25, 38
Autonomy – 13, 26, 39
Scores for each of the 13 functions range from 0 to 6.

Reproduced with permission from E. David Klonsky, PhD, Department of Psychology, University of British Columbia, and Catherine R. Glenn, PhD, Department of Psychology, University of Rochester.

Graphic 116871 Version 2.0

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Inventory of Statements About Self-Injury