The Association between Nonsuicidal Self-Injury and Perfectionism in Adolescence: The Role of Mental Disorders

Round 1

Reviewer 1 Report

I want to commend the authors for conducting a comprehensive study that explores the prevalence of NSSI (Non-Suicidal Self-Injury) among community adolescents and its association with various factors, especially maladaptive perfectionism and mental disorders. The study's findings shed light on a critical issue affecting adolescents and provide valuable insights for both prevention and intervention strategies. 

I would like to provide the following suggestions for improving the quality of this research:

1. Introduction: 

Definition of NSSI: The definition of NSSI is clear, but it could be made more concise for easier readability. For example: "Nonsuicidal self-injury (NSSI) refers to deliberate self-inflicted harm without suicidal intent [1–3]."

Prevalence of NSSI: When presenting statistics, consider grouping them together to enhance readability, like this: "The lifetime prevalence of NSSI among adolescents ranges from 17.1% to 46.5% in community samples [7,10–15] and from 51.3% to 82.4% in clinical adolescent populations [6–9]. Moreover, the prevalence of NSSI in adolescents has been on the rise over the past 15 years [4,16]."

Perfectionism Definition: The definition of perfectionism is comprehensive. However, you could simplify it for clarity: "Perfectionism is commonly defined as setting excessively high performance standards, accompanied by overly critical self-evaluations [23] (p. 450)."

Connection Between Perfectionism and NSSI: The paragraph explaining the relationship between perfectionism and NSSI is comprehensive. However, you might consider reorganizing it for better flow. Start with the key findings and then delve into the factors contributing to this relationship.

Research Gap: The discussion of the research gap is clear. However, it might be useful to explicitly state that this study aims to address this gap, providing a smoother transition into the study's objectives.

Research Hypotheses: The hypotheses are well-stated. Consider rephrasing them for conciseness: "Our study hypothesizes: 1) The association between perfectionism dimensions and NSSI is mediated by comorbid mental disorders. 2) Maladaptive perfectionism is more strongly associated with the intrapersonal function of NSSI than the interpersonal motivation, and this relationship is mediated by higher levels of mental disorders."

2. Materials and Methods:

1) Ethical Approval: Specify the year when the study was conducted, as this is important for understanding the timeline. Clarify whether the study received ethical approval before or after data collection began.

2) Mention any specific software or packages used for the statistical analysis in R (e.g., "We conducted statistical analysis using R, version 3.5.1, and employed packages such as [list packages]"). This can help readers replicate the analysis if needed. Specify the significance level (α) used for hypothesis testing (e.g., "An α level of 0.05 was used for all hypothesis tests").

3) Data Collection During COVID-19 Pandemic: Provide more details about how the transition to online data collection was managed during the COVID-19 pandemic. Explain any changes made to the data collection process and how they might have affected the study's methodology.

4) Participant Attrition: Briefly explain the reasons for participant attrition, especially the withdrawal of five adolescents and the non-availability of thirteen participants. This can help readers understand any potential biases in the sample.

5) Provide a brief description of what mixed graphical network models are and how they were applied in your analysis. This will help readers understand the significance of this approach.

3. Discussion: 

1) Prevalence of NSSI: Consider starting with a concise summary of the high prevalence of NSSI in the community adolescent population. Then, transition into your study's findings to make the connection more explicit.

2) Prevalence Rates in Your Sample: When discussing your own study's prevalence rates, it would be helpful to include some context or comparison to the existing literature. For example, you can briefly mention how your rates align with or differ from previous studies.

3) Potential Explanations for High Prevalence: When discussing the 68.09% high prevalence rate in your sample before the COVID-19 pandemic, consider providing a concise hypothesis or explanation for this unusually high rate. This will help readers understand the significance of your findings.

4) Role of Social Networking Sites: While you mention the role of social networking sites in NSSI, it might be beneficial to provide a brief explanation or example to illustrate how these sites can influence NSSI behavior among adolescents. This will make your argument more concrete.

5) Complex Relationship Between NSSI, Perfectionism, and Mental Disorders: When discussing the complex relationship between NSSI, perfectionism, and mental disorders, consider breaking down this information into smaller, more digestible sections. Start with NSSI and mental disorders, then discuss NSSI and perfectionism, and finally, the interplay between all three. This will improve the flow of your discussion.

6) Discussion of Hypotheses: You've mentioned that your results support the mediating effect of mental disorders on the relationship between perfectionism and NSSI. It might be helpful to reiterate your hypotheses and explicitly state how your findings align with or diverge from these hypotheses.

7) Implications for Prevention and Intervention: Towards the end of your discussion, highlight the practical implications of your findings. How can your results inform prevention and intervention strategies for adolescents at risk of NSSI? Be explicit in connecting your research to potential real-world applications.

8) Limitations: You've mentioned the limitations of your study, but consider grouping them together in a dedicated section for clarity. Additionally, briefly discuss how these limitations might have affected the interpretation of your results.

Regenerate

Moderate editing of English language required

Author Response

REVIEWER 1.

Manuscript ID: ejihpe-2599610

Titel: The Association Between Nonsuicidal Self-injury and Perfectionism in 
Adolescence: The Role of Mental Disorders

I want to commend the authors for conducting a comprehensive study that explores the prevalence of NSSI (Non-Suicidal Self-Injury) among community adolescents and its association with various factors, especially maladaptive perfectionism and mental disorders. The study's findings shed light on a critical issue affecting adolescents and provide valuable insights for both prevention and intervention strategies. 

We would like to thank the Reviewer for taking the time to review our manuscript and for the useful comments and suggestions. Please find our answers to each point below.

I would like to provide the following suggestions for improving the quality of this research:

1. Introduction: 

Definition of NSSI: The definition of NSSI is clear, but it could be made more concise for easier readability. For example: "Nonsuicidal self-injury (NSSI) refers to deliberate self-inflicted harm without suicidal intent [1–3]."

We would like to thank the Reviewer for this suggestion. We modified our manuscript in Introduction section in line 38-39:

"Nonsuicidal self-injury (NSSI), which refers to deliberate self-inflicted harm without suicidal intent [1–3], has become a serious public health concern among adolescents.”

Prevalence of NSSI: When presenting statistics, consider grouping them together to enhance readability, like this: "The lifetime prevalence of NSSI among adolescents ranges from 17.1% to 46.5% in community samples [7,10–15] and from 51.3% to 82.4% in clinical adolescent populations [6–9]. Moreover, the prevalence of NSSI in adolescents has been on the rise over the past 15 years [4,16]."

Based on the Reviewer’s useful suggestion e modified the Introduction section in line 41-44:

“The lifetime prevalence of NSSI among adolescents ranges from 17.1% to 46.5% in community samples [6-11] and from 51.3% to 82.4% in clinical adolescent populations [12-14]. Moreover, the prevalence of NSSI in adolescents has been on the rise over the past 15 years [4,15]."

Perfectionism Definition: The definition of perfectionism is comprehensive. However, you could simplify it for clarity: "Perfectionism is commonly defined as setting excessively high performance standards, accompanied by overly critical self-evaluations [23] (p. 450)."

We would like to thank the Reviewer for this suggestion. We modified our manuscript in Introduction section in line 52-55:

“Perfectionism is a potential risk factor for NSSI engagement [22]. It is conceptualised as a multidimensional construct (with intra- and interpersonal aspects) [23,24], and commonly defined as “setting excessively high performance standards, accompanied by overly critical self-evaluations” [23] (p. 450). "

Connection Between Perfectionism and NSSI: The paragraph explaining the relationship between perfectionism and NSSI is comprehensive. However, you might consider reorganizing it for better flow. Start with the key findings and then delve into the factors contributing to this relationship.

We would like to thank the Reviewer for this useful suggestion. We reorganised our Introduction section in line 38-118:

Nonsuicidal self-injury (NSSI), which refers to deliberate self-inflicted harm without suicidal intent [1–3], has become a serious public health concern among adolescents. Although NSSI is a prevalent phenomenon, it remains hidden in many cases [4], and stigmatisation of it is common among adolescents [5]. The lifetime prevalence of NSSI among adolescents ranges from 17.1% to 46.5% in community samples [6–11] and from 51.3% to 82.4% in clinical adolescent populations [12–14]. Moreover, the prevalence of NSSI in adolescents has been on the rise over the past 15 years [4,15].

NSSI engagement serves several psychological functions, and most individuals use multiple functions [16–19]. Studies focusing on the psychological functions of NSSI support two main factors related to NSSI functionality: (1) intrapersonal (e.g., to manage one’s uncomfortable internal state) and (2) interpersonal (e.g., to influence one’s social environment) motivation [20] and suggest that intrapersonal motives are more prevalent and strongly associated with internalising and externalising mental symptoms than are interpersonal motives [17,19–21].

Perfectionism is a potential risk factor for NSSI engagement [22]. It is conceptualised as a multidimensional construct (with intra- and interpersonal aspects) [23,24], and commonly defined as “setting excessively high performance standards, accompanied by overly critical self-evaluations” [23] (p. 450). Factor analytic studies have distinguished two main factors: (1) maladaptive evaluation concerns (maladaptive) and (2) positive achievement striving (adaptive) [25–29]. In recent years, the prevalence rate of maladaptive perfectionism among community adolescents has also reached alarming levels: 22% to -38% [28–32] and, similar to NSSI, perfectionism also is showing an upward tendency [4,15,33,34].

Until now, only a few studies have explored the function of NSSI among perfectionistic adolescents; moreover, some results are inconsistent. Nock and Prinstein (2005) emphasised the role of the social (interpersonal) function of self-injury and found that psychiatric adolescents who perceive unrealistic high expectations from their environment tend to use self-injury to get support from others or to avoid those perceived expectations [35]. Meanwhile, inconsistent with that, Claes et al. (2012) found, among women diagnosed with eating disorders (EDs), patients who perceived parental criticism had a negative relationship with the cry-for-help function of NSSI behaviour [36]. Other findings, with a community adolescent sample [37] and women ED patients [36], have supported the role of the intrapersonal motivation of NSSI related to self-critical perfectionistic concerns. This evidence suggested that unhealthy perfectionistic people tend to use NSSI in order to handle strong negative emotions. Results among perfectionistic people related to NSSI function may be influenced by the age of the study population, and by the mental disorders examined [22].

Related to the possible pathway between two phenomena, few studies have focused on the examination of direct and indirect mechanisms between NSSI and perfectionism, and several aspects remain unclear [22]. Some results indicate a direct relationship between NSSI and perfectionism [36,38,39] and an indirect effect through rumination and negative affect [39]. Gu et al. [8], in a study of community adolescents, found that psychological distress has a mediating effect on the association between the two phenomena. This suggests that there is an indirect relationship between maladaptive perfectionism and NSSI, which is mediated by emotional distress symptoms [8]. It may also imply that NSSI is used as a maladaptive coping strategy to reduce or communicate unwanted emotional states.

Regardless of the fact that the positive perfectionism dimension is characterised by more adaptive outcomes [27], several studies and metanalytic results have indicated that both perfectionism dimensions (adaptive and maladaptive) [32,40–48] and NSSI [12,49–50] have a significant relationship with several internalising and externalising mental disorders. In addition, both phenomena mean risk factor related to suicidal behaviour [6,12,44,51–55]. Maladaptive perfectionism (evaluation concerns) plays an important role in NSSI engagement [22]. Individuals with maladaptive perfectionism and NSSI tend to be highly self-critical [23,56–58], and unhealthy perfectionistic adolescents and individuals with NSSI engagement report similar difficulties in emotion regulation [59,60]. People with maladaptive perfectionism tend to react to failure with elevated levels of shame, guilt, depression, anxiety, and anger [61–63], and these strong negative emotions [61–63] may motivate them to self-harm [64]. These results confirm findings that emphasised that perfectionistic individuals tend to engage in NSSI because of self-punishment, self-torture, and cry-for-help motives [36], and affect regulation and the self-punishment function of NSSI are the most common motivations for this behaviour [2,19], which plays an important role in shame coping [65,66].

Adolescents with history of NSSI rate their family life satisfaction, physical and mental health, and global well-being significantly lower than adolescents without NSSI [12]. Given the high prevalence of NSSI, and owing to its significant association with a range of several comorbid internalising and externalising mental disorders [12,49], especially with suicidal behaviour [6,67], NSSI has been recognised as a long-lasting public health problem among adolescents [49,68]. It is critical to explore this behaviour to develop interventions and treatments in order to support those struggling with NSSI engagement [19,69].

Although both NSSI and perfectionism are public health concerns and have a high prevalence rate in the adolescent years, more detailed explorations of NSSI behaviour among community adolescent samples in connection with perfectionism are lacking. Much of the literature has focused on adults, although prevalence rates related to both phenomena are high in the adolescent years. On the basis of the previous literature, little evidence related to perfectionism and NSSI, especially among community adolescent samples, is available, which raises further issues. The primary aim of this study was to replace the missing literature evidence and to explore the relationship between perfectionism dimensions and different NSSI functions, to examine the potential mediating effect of different mental disorders on the relationship between them. Our hypotheses were as follows:

Research Gap: The discussion of the research gap is clear. However, it might be useful to explicitly state that this study aims to address this gap, providing a smoother transition into the study's objectives.

Based on the Reviewer’s comment we modified the Introduction section in line 115-116:

“The primary aim of this study was to replace the missing literature evidence and to explore the relationship between perfectionism dimensions and different NSSI functions, to examine the potential mediating effect of different mental disorders on the relationship between them.”

Research Hypotheses: The hypotheses are well-stated. Consider rephrasing them for conciseness: "Our study hypothesizes: 1) The association between perfectionism dimensions and NSSI is mediated by comorbid mental disorders. 2) Maladaptive perfectionism is more strongly associated with the intrapersonal function of NSSI than the interpersonal motivation, and this relationship is mediated by higher levels of mental disorders."

We would like to thank the Reviewer for this suggestion. We modified our manuscript in Introduction section in line 120-124:

“Hypothesis 1: The association between perfectionism dimensions and NSSI is mediated by comorbid mental disorders.

Hypothesis 2: Maladaptive perfectionism is more strongly associated with the intrapersonal function of NSSI than the interpersonal motivation, and this relationship is mediated by higher levels of mental disorders.”

2. Materials and Methods: 

1) Ethical Approval: Specify the year when the study was conducted, as this is important for understanding the timeline. Clarify whether the study received ethical approval before or after data collection began.

Based on the Reviewer’s comment, we modified the Materials and Methods section in line 129-131:

“This study was conducted in accordance with the Declaration of Helsinki and approved by the National Scientific and Ethical Committee of the Medical Research Council, Hungary (Protocol No. 54023-5/2018/EKU, IV/8167-3/2020/EKU). The study was approved on 20 November 2018 (Protocol No. 54023-5/2018/EKU). After receiving ethical approval, data collection started on 5 June 2019.”

2) Mention any specific software or packages used for the statistical analysis in R (e.g., "We conducted statistical analysis using R, version 3.5.1, and employed packages such as [list packages]"). This can help readers replicate the analysis if needed. Specify the significance level (α) used for hypothesis testing (e.g., "An α level of 0.05 was used for all hypothesis tests").

We would like to thank the Reviewer for this comment. We modified our manuscript in Materials and Methods section in line 309:

“For network estimations, the bootnet package was used [88].”

3) Data Collection During COVID-19 Pandemic: Provide more details about how the transition to online data collection was managed during the COVID-19 pandemic. Explain any changes made to the data collection process and how they might have affected the study's methodology.

We would like to thank the Reviewer for this comment. We modified our manuscript in Materials and Methods section in line 141-176:

“Our study has a cross-sectional study design. Sample was conducted with a Hungarian convenience sample of adolescents. Our research group developed a new school mental health preserving prevention program [70] and several schools contacted us to request this prevention program, because teachers perceived that students have mental problems. All participants took part in our study before the prevention program. Participants were recruited from Hungarian secondary schools during a recruitment period spanning 5 June 2019 to 23 September 2022. The instruments consisted of a structured diagnostic interview (see below) and self-report questionnaires. After informed consent was obtained, participants were assessed with the structured diagnostic interview by a trained researcher in separated classrooms in the school. The digital version of the self-report questionnaires was completed in the computer rooms of the schools in the presence of research staff, providing the opportunity to ask questions. Parents / caregivers received the link to the online parent self-report questionnaire by email. When technical possibilities were not available in the schools, questionnaires were carried out on paper. Following the outbreak of the COVID-19 pandemic (March 2020), it was forbidden to go personally to schools due to the safety regulations, which made in-person data collection impossible. We had to modify our data collection process and completely switch to online data collection. Our study was approved again regarding the methodological changes by the National Scientific and Ethical Committee of the Medical Research Council, Hungary (IV/8167-3/2020/EKU). After gaining the new, extended ethical approval, adolescents in the schools were informed through an introduction video of our research group, and informed consent was shared and gained with help of teachers and principals of the schools. After the adolescents and their parents / caregivers gave their written informed consent, we contacted them by phone, and they were also informed verbally about how online data collection will be conducted. In the case of the structured diagnostic interview, a member of our research staff sent a link by email separately for every adolescent, and the structured diagnostic interview was completed in a two-person situation with help of online video connection at a previously scheduled appointment. Regarding the self-report questionnaires, a link to the digital version of the self-report questionnaire package was sent individually by email to the adolescents.  The self-report questionnaires were then completed in the computer rooms of the schools. During the time of the completion, our research staff ensured online video connection and provided opportunity for the participants to ask questions if necessary. Twenty-four adolescents were tested online by structured diagnostic interview. After we had the opportunity to visit the schools in person again, we continued our data collection personally. When the COVID-19 pandemic regulations made it possible to visit the schools in person again, we continued our data collection personally.”

4) Participant Attrition: Briefly explain the reasons for participant attrition, especially the withdrawal of five adolescents and the non-availability of thirteen participants. This can help readers understand any potential biases in the sample.

We would like to thank the Reviewer for this suggestion. After the adolescents and their parents agreed to participate in our study and signed the consent form, the following two difficulties arose, resulting in not including some of the participants in our study: 1. they were unavailable at the time of the study (e.g. they were not in school on the days we went to collect data) or 2. had since withdrawn their consent to the study (it happened online and in person as well). During the COVID-19 pandemic we collected our data online, and even though we had arranged an appointment for the interview with the adolescents, it happened that they were not available by phone at the time and we were unable to reach them again later. Overall, there were more drop-outs in the online data collection, making it more difficult to reach participants in this way.

We extended the Materials and Methods section in line 177-184 with the following:

“A total of one hundred eighty-three 13- to 18-year-old participants gave written informed consent; of these, five adolescents withdrew their participation, and thirteen were not available for data collection despite their prior consent (e.g., they were absent from school on the days of the data collection). During the COVID-19 pandemic we collected our data online, and even though we had arranged a scheduled appointment for the interview with the adolescents, it happened that they were not available by phone at the time and we were unable to reach them again later. Overall, there were more drop-outs during the online data collection, making it more difficult to reach participants in this way.”

5) Provide a brief description of what mixed graphical network models are and how they were applied in your analysis. This will help readers understand the significance of this approach.

We would like to thank the Reviewer for this comment. We highlighted the importance of the network analyses in our previous article also in the Introduction and Methods section. That is why in this article we mentioned it in line 312:

Information related to the literature background of network modelling was detailed in a previous study [12].

Gyori, D.; Farkas, B.F.; Horvath, L.O.; Komaromy, D.; Meszaros, G.; Szentivanyi, D.; Balazs, J. The Association of Nonsuicidal Self-Injury with Quality of Life and Mental Disorders in Clinical Adolescents-A Network Approach. Int. J. Environ. Res. Public Health 2021, 18, 1840, doi:10.3390/ijerph18041840.

However according to your suggestion, we modified our manuscript in Statistical Analyses section in line 304-309:

“Network modelling provides a test of the potential explanatory mechanism between examined variables. It enables us to show the different pathways between examined variables, how mental disorders, perfectionism dimensions, and NSSI can influence each other in different ways. Network modelling is important in clinical study providing a comprehensive model related to complex interrelationships [88, 89].”

3. Discussion: 

1) Prevalence of NSSI: Consider starting with a concise summary of the high prevalence of NSSI in the community adolescent population. Then, transition into your study's findings to make the connection more explicit.

We would like to thank the Reviewer for this useful suggestion. We reorganised the first paragraph of the Discussion section:

“Many lines of evidence suggest that, among the community adolescent population, NSSI has reached an extremely high prevalence rate of 17.1% to 46.5% [6-11,21], and findings from longitudinal cohort studies and recent review studies show an upward trend [15,90]. Meta-analytic results related to past decade show an increasing trend toward more serious self-injuries among nonclinical adolescents [4]. Related to this phenomenon, Xiao et al. (2022) mentioned the important role of the development of social networking sites, growing learning expectations for youth, and maladaptive coping mechanisms, in addition to changes and problems in personal relationships. Social networking sites (e.g., Instagram) have an important priority in most adolescents’ daily lives [91,92], and the number of online sites that promote self-injury activities (e.g. NSSI wounds photos, videos, posts), is growing and provides the opportunity for youth to contact other people who engage in NSSI [91,92]. Social positive reinforcement may be an important factor in the maintaining of posting NSSI online content. Severe wound picture lead to elevated level of interest and empathetic comments, which can affect bidirectional and encourage further posting of severe self-injury [92].Vulnerable adolescents tend to use social networking websites to benefit from social support [90], and other self-injurers online friends may encourage them to self-harm [92,93]. These virtual self-injuring communities can serve a potential identity-formation outlet for those who have problems with this developmental process [92,94], and identity confusion is a significant predictor of NSSI engagement among adolescents [38]. Although social media activities have many negative consequences (negative comments, encouragement to self-harm, triggering, competition) there are also benefits for people who self-injure (positive sense of community, reduction of social isolation, anonymity, support, reduction of self-injury urges) [95,96].

Our results may support this increasing trend in community adolescents; for example, in our nonclinical sample, 61.64% of adolescents reported engaging in NSSI.”

2) Prevalence Rates in Your Sample: When discussing your own study's prevalence rates, it would be helpful to include some context or comparison to the existing literature. For example, you can briefly mention how your rates align with or differ from previous studies.

We would like to thank the Reviewer for this suggestion. We modified our manuscript in line 504-518:

​​Our results may support this increasing trend in community adolescents; for example, in our nonclinical sample, 61.64% of adolescents reported engaging in NSSI. Both girls (61.54%) and boys (61.90%) reported extremely high and approximately equal prevalence rates of NSSI, even though previous meta-analytic results have emphasised higher NSSI engagement among girls than boys [4,97]. On the basis of some additional analysis related to the prevalence rate of NSSI, and the fact that this high prevalence rate cannot be explained by a COVID-19 pandemic effect during our recruitment period, the prevalence rate in our adolescent sample before the first COVID-19 wave was 68.09%, and during and after the second and third waves it was 43.33%. 43.33% prevalence rate similar to the recent rates to other Hungarian community sample (41.2%) [21] and to other international results in Swedish 41.6% [8], Chinese 47.1% [98] and Brazil 45.3% [99] community adolescent sample. The 68.09% NSSI prevalence rate before the first COVID-19 wave in our sample is higher than recent Hungarian and international prevalence rate, and the exact reason for this high prevalence rate is unknown. We can provide only a hypothetical explanation. Our research group works in the field of school-based adolescents mental health improvement, suicide prevention [100,101]. We developed a new school-based mental health promoting prevention program [70] and several schools contacted us to request this prevention program as teachers perceived that students might have mental problems. All participants took part in our study before the prevention program. The high prevalence rates of NSSI and mental disorders derived from this population, and our findings show how much mental health preserving prevention programs are needed in schools. Our results represent the mental state of those high school students, where the sensitive attention of teachers recognised the potential problems.

3) Potential Explanations for High Prevalence: When discussing the 68.09% high prevalence rate in your sample before the COVID-19 pandemic, consider providing a concise hypothesis or explanation for this unusually high rate. This will help readers understand the significance of your findings.

We would like to thank the Reviewer for this suggestion. Please read the answer also at the previous point.

We modified the manuscript with this information in Methods section in line 142-145:

“Our research group developed a new school mental health preserving prevention program [70] and several schools contacted us to request this prevention program, because teachers perceived that students have mental problems. All participants took part in our study before the prevention program.”

4) Role of Social Networking Sites: While you mention the role of social networking sites in NSSI, it might be beneficial to provide a brief explanation or example to illustrate how these sites can influence NSSI behavior among adolescents. This will make your argument more concrete.

We would like to thank the Reviewer for this suggestion. We modified our manuscript in the Discussion section in line 480-495:

Social networking sites (e.g., Instagram) have an important priority in most adolescents’ daily lives [91,92], and the number of online sites that promote self-injury activities (e.g. NSSI wounds photos, videos, posts), is growing and provides the opportunity for youth to contact other people who engage in NSSI [91,92]. Social positive reinforcement may be an important factor in the maintaining of posting NSSI online content. Severe wound picture lead to elevated level of interest and empathetic comments, which can affect bidirectional and encourage further posting of severe self-injury [92].Vulnerable adolescents tend to use social networking websites to benefit from social support [90], and other self-injurers online friends may encourage them to self-harm [92,93]. These virtual self-injuring communities can serve a potential identity-formation outlet for those who have problems with this developmental process [92,94], and identity confusion is a significant predictor of NSSI engagement among adolescents [38]. Although social media activities have many negative consequences (negative comments, encouragement to self-harm, triggering, competition) there are also benefits for people who self-injure (positive sense of community, reduction of social isolation, anonymity, support, reduction of self-injury urges) [95,96].

5) Complex Relationship Between NSSI, Perfectionism, and Mental Disorders: When discussing the complex relationship between NSSI, perfectionism, and mental disorders, consider breaking down this information into smaller, more digestible sections. Start with NSSI and mental disorders, then discuss NSSI and perfectionism, and finally, the interplay between all three. This will improve the flow of your discussion.

We would like to thank the Reviewer for this suggestion. We reorganized our Discussion section our manuscript according it in line 473-648:

Many lines of evidence suggest that, among the community adolescent population, NSSI has reached an extremely high prevalence rate of 17.1% to 46.5% [6-11,21], and findings from longitudinal cohort studies and recent review studies show an upward trend [15,90]. Meta-analytic results related to the past decade show an increasing trend toward more serious self-injuries among nonclinical adolescents [4]. Related to this phenomenon, Xiao et al. (2022) mentioned the important role of the development of social networking sites, growing learning expectations for youth, and maladaptive coping mechanisms, in addition to changes and problems in personal relationships. Social networking sites (e.g., Instagram) have an important priority in most adolescents’ daily lives [91,92], and the number of online sites that promote self-injury activities (e.g. NSSI wounds photos, videos, posts), is growing and provides the opportunity for youth to contact other people who engage in NSSI [91,92]. Social positive reinforcement may be an important factor in the maintaining of posting NSSI online content. Severe wound picture lead to elevated level of interest and empathetic comments, which can affect bidirectional and encourage further posting of severe self-injury [92]. Vulnerable adolescents tend to use social networking websites to benefit from social support [90], and other self-injurers online friends may encourage them to self-harm [92,93]. These virtual self-injuring communities can serve a potential identity-formation outlet for those who have problems with this developmental process [92,94], and identity confusion is a significant predictor of NSSI engagement among adolescents [38]. Although social media activities have many negative consequences (negative comments, encouragement to self-harm, triggering, competition) there are also benefits for people who self-injure (positive sense of community, reduction of social isolation, anonymity, support, reduction of self-injury urges) [95,96].

Our results may support this increasing trend in community adolescents; for example, in our nonclinical sample, 61.64% of adolescents reported engaging in NSSI. Both girls (61.54%) and boys (61.90%) reported extremely high and approximately equal prevalence rates of NSSI, even though previous meta-analytic results have emphasised higher NSSI engagement among girls than boys [4,97]. On the basis of some additional analysis related to the prevalence rate of NSSI, and the fact that this high prevalence rate cannot be explained by a COVID-19 pandemic effect during our recruitment period, the prevalence rate in our adolescent sample before the first COVID-19 wave was 68.09%, and during and after the second and third waves it was 43.33%. 43.33% prevalence rate similar to the recent rates to other Hungarian community sample (41.2%) [21] and to other international results in Swedish 41.6% [8], Chinese 47.1% [98] and Brazil 45.3% [99] community adolescent sample. The 68.09% NSSI prevalence rate before the first COVID-19 wave in our sample is higher than recent Hungarian and international prevalence rate, and the exact reason for this high prevalence rate is unknown. We can provide only a hypothetical explanation. Our research group works in the field of school-based adolescents mental health improvement, suicide prevention [100,101]. We developed a new school-based mental health promoting prevention program [70] and several schools contacted us to request this prevention program as teachers perceived that students might have mental problems. All participants took part in our study before the prevention program. The high prevalence rates of NSSI and mental disorders derived from this population, and our findings show how much mental health preserving prevention programs are needed in schools. Our results represent the mental state of those high school students, where the sensitive attention of teachers recognised the potential problems.

Many studies have indicated that adolescence is a sensitive developmental period that drives both neural and social changes and increases vulnerability to emotion regulation problems and psychiatric disorders (e.g., depression and anxiety) [102,103]. Similar to previous studies [12,49–51] our results also emphasise the high prevalence rate of internalising and externalising psychiatric disorders among adolescents who engage in NSSI. An important highlighting result is that the highest comorbid mental disorder in NSSI group is ASD (52.22%); however, questions on the MINI-KID about ASD diagnoses mainly serve to exclude the diagnosis rather than establish it, so further investigations in this field are needed [71–76]. Our findings are in line with those of previous studies [104,105] and suggest that self-injurious adolescents tend to report higher levels of depressive symptoms, anxiety, and suicidality. In our community adolescent sample, 38.89% of youth who engaged NSSI also had anxiety disorders, and 36.67% reported mood disorders and suicidality.

To our knowledge, this study is the first to examine all relevant mental disorders among adolescents in connection with different perfectionism dimensions and NSSI engagement. Investigating the complex nature of the association between NSSI and perfectionism provides relevant information for prevention and intervention regarding NSSI engagement. Hypothesis 1 stated that the association between perfectionism dimensions and NSSI is mediated by comorbid mental disorders. Our results offer preliminary evidence supporting the mediating effect of mental disorders, especially anxiety disorders, on the relationship between maladaptive perfectionism and NSSI engagement, therefore our Hypothesis 1 was supported, but additional research is necessary to confirm these results with larger samples. The importance and novelty of the topic are demonstrated by the fact that only a few recent studies have explored the potential moderating and mediating effect between two phenomena, and our findings suggest that individuals with perfectionistic concerns and doubts are at greater risk for anxiety disorders and therefore greater risk for NSSI. These findings confirm previous evidence that has emphasised the mediating role of negative affect, psychological distress between two phenomena [8,39], and that maladaptive perfectionism is one of the main key factors related to anxiety symptoms [106,107].

Although previous studies have suggested that the intrapersonal functions of NSSI engagement are more prevalent, and more strongly associated with internalising and externalising mental symptoms, than interpersonal motives [17,19–21], the adolescents in our sample used both NSSI motivations at approximately equal rates. In addition, similar to previous studies [16–19], the majority (80.88%) of them used multiple functions regarding NSSI engagement. In contrast to Hypothesis 2 - Maladaptive perfectionism is more strongly associated with the intrapersonal function of NSSI than the interpersonal motivation, and this relationship is mediated by higher levels of mental disorders - our results did not supported Hypothesis 2 and show that unhealthy perfectionistic adolescents tend to commit self-harm for both intrapersonal and interpersonal motivations to a similar extent and that anxiety disorders have a central role in this mechanism. Although previous results among community adolescents have shown that maladaptive perfectionistic adolescents tend to use self-injury primarily because of intrapersonal motivation [37], our results demonstrate that the relationship between maladaptive perfectionistic tendencies and NSSI engagement seems to be independent of self-injury motives and that unhealthy perfectionistic adolescents tend to use self-injury to the same extent to escape from negative emotional states and as a means of communicating or exerting interpersonal influence. We should mentioned that there is a methodological difference between the  present study and Reinhardt et al’s, because Reinhardt et al. (2021) used the original categorisation of NSSI motives regarding the ISAS [21] in which anti-suicide motives belonged to intrapersonal functionality. After the Hungarian adaptation of ISAS [21] was published, we assessed NSSI function according to the ISAS-HU, in which the anti-suicide function belongs to the interpersonal motivation. The anti-suicide function of NSSI serves as coping against suicidal thoughts and attempts [2,19]. More than one third of our community adolescents with a history of NSSI reported suicidal behaviour according to a structured psychiatric interview, so the anti-suicide function may have influenced the results between the two Hungarian studies. We confirmed it with additional analysis. We categorised again the NSSI function according to the original categorisation of NSSI motives regarding the ISAS [17]. Our additional results confirmed previous studies, which emphasised the higher rate of NSSI intrapersonal function [17,19–21] and the stronger association between NSSI intrapersonal function and maladaptive perfectionism [36,37] (see Table A4-A6 in Appendix). Overall, 95.58 % (n = 65) adolescents who engaged in NSSI (n = 68) reported using the intrapersonal motivation of NSSI, and 85.29% (n = 58) reported using the interpersonal motivation. There was a significant difference related to the prevalence of NSSI functions (intrapersonal, interpersonal), χ2 (1, N = 134) = 77.69, p < .0001. According to this original categorisation of NSSI motives regarding the ISAS [17], our additional findings supported Hypothesis 2.

The strong association between anxiety disorders and NSSI engagement has been proved by meta-analytic review evidence [108], and one of the main functions of NSSI is the emotion regulation and the reduction of anxiety [19,109]. Anxiety disorders among adolescents are a relevant predictor of experiential avoidance [110], and the Experiential Avoidance Model (EAM) [111] emphasises that NSSI behaviour serves as a means to escape undesirable emotional experiences, and the temporary relief after self-harm repeatedly reinforces this maladaptive behaviour. It is essential that individuals with anxiety symptoms do not negatively judge their internal emotional states because this attitude can decrease the risk related to NSSI engagement [112]; however, the repetitive self-critical thinking and rumination of maladaptive perfectionistic individuals increase psychological distress and negative emotions [39,56]. The Emotional Cascade Model (ECM) [113] emphasises the mutually reinforcing mechanism between ruminative thoughts and negative emotions. NSSI breaks this aversive reciprocal cycle, and distracts one’s focus away from negative emotional states with physical acts of self-injury [113]. Our results confirm previous evidence that has emphasised that maladaptive perfectionism may play a significant role in these emotional cascades [39].

Maladaptive perfectionistic adolescents try to seem perfect and competent in every daily situation in school, but their perfectionist pursuits often result in rejection and bullying form peers [45], as well as social isolation, and the social hopelessness of these adolescents can elevate the risk for several mental disorders (e.g., anxiety, depression) [45] and suicidal risk [114]. Maladaptive perfectionistic people tend to be seen as invulnerable and try to hide their real emotions after a failure and, because of a high level of distress, to escape from situations in which they have to speak in front of classmates [115,116]. The perfectionistic self-presentation of adolescents, the need to look perfect and invulnerable to other people, is significant risk factor related to anxiety symptoms [115]. Social network sites also provide an opportunity for superficial contact without really showing oneself [116,117]. Unhealthy perfectionist adolescents make great efforts to keep any sign of their anxiety invisible, and they tend to avoid seeking help; therefore, it is really hard to recognise the urgent need for help when they are hiding behind a mask of perfection [116].

Our findings confirm previous results that have suggested that the importance of order and neatness may be a healthy dimension of perfectionism [29,84] and a protective factor against NSSI engagement [102] independent of any mediating effect of mental disorders. This may mean that the importance of order and neatness refers to the ability to manage and control one’s daily life and emotional experiences, and adolescents with low organisation subscale scores may perceive their feelings and everyday situation as unmanageable, and thus NSSI behaviour gives them a ‘sense of control’ [104] (p. 583).

In summary, our results confirm and indicate that adolescents who report higher rate of maladaptive perfectionism concerns are more likely to engage in NSSI, which is consistent with previous systematic review evidence that have highlighted the important role of perfectionistic concern related to NSSI engagement [22]. Our study serves implications for prevention and intervention related to adolescent NSSI. Prevention and intervention should focus on the reduction of potential risk factors related to NSSI. Our findings emphasise that teachers and professionals should pay attention to unrealistic high standards parallel with actual ability and should support reachable goals setting [8,39]. Psychological interventions have to focus on the reduction of maladaptive perfectionistic tendencies (concern over mistakes, doubt about action) to decrease the constant state of anxiety [118] which may lead to lower incidence of NSSI. Cognitive-behavioral therapy (CBT) has positive effect in perfectionism intervention [118], and it is worth considering the introduction of mindfulness techniques in school classes, which are effective in case of emotion dysregulation [118] and decrease the relationship between perfectionism and emotional distress symptoms as well as its relationship with NSSI engagement [8]. According to our result, increasing the importance of order and neatness is protective against NSSI and may help adolescents to organise daily tasks which can lead to the sense that they can control and manage everyday situations [104]. Healthy perfectionistic students believe that teachers with demand for organisation and neatness in schoolwork helped them to organise in their daily life [119]. Mental health prevention school programs [70,100,101] are essential because the recognition of maladaptive perfectionistic tendencies is problematic for parents and teachers [119], and almost one third of gifted adolescents have high levels of maladaptive perfectionist characteristics [119]. They do not seek help, try to hide their feelings and problems [115] and are unable to recognize the negative consequences of their continuous concern and self-criticism [119]. Maladaptive perfectionists often perceive high parental expectations and criticism [119], that is why the involvement of family members in intervention strategy would be beneficial.

6) Discussion of Hypotheses: You've mentioned that your results support the mediating effect of mental disorders on the relationship between perfectionism and NSSI. It might be helpful to reiterate your hypotheses and explicitly state how your findings align with or diverge from these hypotheses.

We would like to thank the Reviewer for this suggestion. We modified the Discussion section in line 536-540 and 554-557:

“Hypothesis 1 stated that the association between perfectionism dimensions and NSSI is mediated by comorbid mental disorders. Our results offer preliminary evidence supporting the mediating effect of mental disorders, especially anxiety disorders, on the relationship between maladaptive perfectionism and NSSI engagement, therefore our Hypothesis 1 was supported, but additional research is necessary to confirm these results with larger samples.”

Although previous studies have suggested that the intrapersonal functions of NSSI engagement are more prevalent, and more strongly associated with internalising and externalising mental symptoms, than interpersonal motives [17,19–21], the adolescents in our sample used both NSSI motivations at approximately equal rates. In addition, similar to previous studies [16–19], the majority (80.88%) of them used multiple functions regarding NSSI engagement. In contrast to Hypothesis 2 - Maladaptive perfectionism is more strongly associated with the intrapersonal function of NSSI than the interpersonal motivation, and this relationship is mediated by higher levels of mental disorders - our results did not supported Hypothesis 2 and show that unhealthy perfectionistic adolescents tend to commit self-harm for both intrapersonal and interpersonal motivations to a similar extent and that anxiety disorders have a central role in this mechanism.

We mentioned in our study that there is a methodological difference between our study and previous study which used the original categorisation of NSSI motives regarding the ISAS [21] in which anti-suicide motives belonged to intrapersonal functionality. After the Hungarian adaptation of ISAS [21] was published, we assessed NSSI function according to the ISAS-HU, in which the anti-suicide function belongs to the interpersonal motivation. The anti-suicide function of NSSI serves as coping against suicidal thoughts and attempts [2,19]. More than one third of our community adolescents with a history of NSSI reported suicidal behaviour according to a structured psychiatric interview, so the anti-suicide function may have influenced the results. 

We did additional analysis to this statement. We categorised again the NSSI function according to original categorisation of NSSI motives regarding the ISAS, and our results confirmed previous results, which emphasised the higher rate of NSSI intrapersonal function.

We modified our manuscript in line 575-585:

“We confirmed it with additional analysis. We categorised again the NSSI function according to the original categorisation of NSSI motives regarding the ISAS [17]. Our additional results confirmed previous studies, which emphasised the higher rate of NSSI intrapersonal function [17,19–21] and the stronger association between NSSI intrapersonal function and maladaptive perfectionism [36,37] (see Table A4-A6 in Appendix). Overall, 95.58 % (n = 65) adolescents who engaged in NSSI (n = 68) reported using the intrapersonal motivation of NSSI, and 85.29% (n = 58) reported using the interpersonal motivation. There was a significant difference related to the prevalence of NSSI functions (intrapersonal, interpersonal), χ2 (1, N = 134) = 77.69, p < .0001. According to this original categorisation of NSSI motives regarding the ISAS [17], our additional findings supported Hypothesis 2.”

We added new table related this statistical analysis in Appendix A section:

Table A4. Associations between perfectionism dimensions and NSSI functions (original ISAS categorisation)

Note. FMPS = Frost Multidimensional Perfectionism Scale; CMD = Concern Over Mistakes and Doubts About Actions subscales; PEC = Parental Expectations and Criticism subscales; PS = Personal Standards subscale; O = Organization subscale; NSSI = nonsuicidal self-injury.

SE – Standard Error, t-Value —T- tests, df- degrees of freedom, p – Level of significance. *p <0.05. **p < 0.01.

Table A5. Associations between perfectionism dimensions and NSSI functions (original ISAS categorisation) after controlling for the effect of mental disorders.

Note. FMPS = Frost Multidimensional Perfectionism Scale; CMD = Concern Over Mistakes and Doubts About Actions subscales; PEC = Parental Expectations and Criticism subscales; PS = Personal Standards subscale; O = Organization subscale; NSSI = nonsuicidal self-injury.

SE – Standard Error, t-Value —T- tests, df- degrees of freedom, p – Level of significance. *p < 0.05. **p < 0.01.

Table A6. Associations between perfectionism dimensions and anxiety disorders.

Note. FMPS = Frost Multidimensional Perfectionism Scale; CMD = Concern Over Mistakes and Doubts About Actions subscales; PEC = Parental Expectations and Criticism subscales; PS = Personal Standards subscale; O = Organization subscale; NSSI = nonsuicidal self-injury.

SE – Standard Error, t-Value —T- tests, df- degrees of freedom, p – Level of significance.

**p < 0.01

7) Implications for Prevention and Intervention: Towards the end of your discussion, highlight the practical implications of your findings. How can your results inform prevention and intervention strategies for adolescents at risk of NSSI? Be explicit in connecting your research to potential real-world applications.

We would like to thank the Reviewer for this suggestion. We modified our manuscript according it in line 625-648:

“In summary, our results confirm and indicate that adolescents who report higher rate of maladaptive perfectionism concerns are more likely to engage in NSSI, which is consistent with previous systematic review evidence that have highlighted the important role of perfectionistic concern related to NSSI engagement [22]. Our study serves implications for prevention and intervention related to adolescent NSSI. Prevention and intervention should focus on the reduction of potential risk factors related to NSSI. Our findings emphasise that teachers and professionals should pay attention to unrealistic high standards parallel with actual ability and should support reachable goals setting [8,39]. Psychological interventions have to focus on the reduction of maladaptive perfectionistic tendencies (concern over mistakes, doubt about action) to decrease the constant state of anxiety [118] which may lead to lower incidence of NSSI. Cognitive-behavioral therapy (CBT) has positive effect in perfectionism intervention [118], and it is worth considering the introduction of mindfulness techniques in school classes, which are effective in case of emotion dysregulation [118] and decrease the relationship between perfectionism and emotional distress symptoms as well as its relationship with NSSI engagement [8]. According to our result, increasing the importance of order and neatness is protective against NSSI and may help adolescents to organise daily tasks which can lead to the sense that they can control and manage everyday situations [104]. Healthy perfectionistic students believe that teachers with demand for organisation and neatness in schoolwork helped them to organise in their daily life [119]. Mental health prevention school programs [70,100,101] are essential because the recognition of maladaptive perfectionistic tendencies is problematic for parents and teachers [119], and almost one third of gifted adolescents have high levels of maladaptive perfectionist characteristics [119]. They do not seek help, try to hide their feelings and problems [115] and are unable to recognize the negative consequences of their continuous concern and self-criticism [119]. Maladaptive perfectionists often perceive high parental expectations and criticism [119], that is why the involvement of family members in intervention strategy would be beneficial. 

8) Limitations: You've mentioned the limitations of your study, but consider grouping them together in a dedicated section for clarity. Additionally, briefly discuss how these limitations might have affected the interpretation of your results.

We would like to thank the Reviewer for this suggestion. We prepare a separate Limitation section in our manuscript in line 649-663:

“Our findings need to be interpreted in light of the following limitations. Our evidence is based on cross-sectional study design; that is why they do not provide information related to causality. NSSI was assessed as an outcome variable, and we examined its predictors and the association between them. A longitudinal study, focusing on a potential mediating effect, is required to provide evidence for a causal relationship between NSSI and maladaptive perfectionism. We used the MINI-KID interview for diagnostic assessment, and it contains questions only related to borderline personality disorder and there are no questions regarding other forms of personality disorders. According to the instructions of the MINI-KID interview, the ASD diagnoses based on the MINI-KID should be investigated more thoroughly by a licensed child- and adolescent psychiatrist. It did not happen in our study. We used self-report questionnaires for the assessment of perfectionism and NSSI. Our study should be considered preliminary because of the small sample size and the fact that it was conducted with a Hungarian convenience sample of adolescents, which constricts the generalisability of the results to wider populations.”

Moderate editing of English language required

We would like to thank the reviewer for this comment. Before the submission process the proofreading of our article was completed by Poof-Reading-Service.com, however we made careful language editing again.

Author Response File: Author Response.pdf

Reviewer 2 Report

ejihpe-2599610

The authors provide a comprehensive review of the association between NSSI and perfectionism, building off a previously published systematic review. Using community convenience sample of adolescents in Hungary, the authors examined the mediation of NSSI and perfectionism by mental disorders. Reasonable measures were used to test the hypotheses, with a strength being the use of a structured diagnostic interview. That said, the results are surprising on many levels and raise questions for this reviewer, as articulated below. 

Major Concerns:

1. The prevalence rates in this sample overshadow the main hypotheses, which are focused on the role of perfectionism and mental disorders (i.e., anxiety), on NSSI engagement and functions. Prevalence rates for NSSI are extremely high for a community sample, higher even than some clinical samples. Further, rates of mental disorders were also exceptionally high, including nearly half of the sample meeting criteria for ASD. Although the authors devote significant text to discussing these unusual findings, given that this was a community sample, I must question the findings. These very high rates raise concern for the validity of the measures used in this study for this population or the representativeness of this convenience community sample, COVID or not. Rates of “suicidality” were also incredibly high, although it is unclear if the authors used the MINI-KID to assess for suicidal ideation or suicidal behavioral as only the term “suicidality” was used. Even relatively uncommon conditions in a community sample, such as psychotic disorders, had prevalence rates of 7-9%. Further, the finding that intrapersonal and interpersonal rates were similarly endorsed in this sample stands in contrast to all studies for which I am aware.

2. Given the finding of no difference in association between interpersonal and intrapersonal motivations with perfectionism, and the unusual inclusion of anti-suicide on the interpersonal domain, it is recommended that the authors should consider a sensitivity analysis in which anti-suicide is included on the intrapersonal domain, as it typically found in factor analyses of the ISAS. In the discussion section, the authors suggest that this may be a reason for the findings; however, they are able to test this directly and therefore should consider doing so.

3. Further, the authors used traditional mediation analysis (i.e., Baron and Kenny), which is generally considered to be inferior to more current causal mediation analysis (see https://doi.org/10.1186/s12874-021-01426-3).

4. The inclusion of the network analysis is unclear given that the authors state that they were underpowered and the effects in the network model were not significant.  If not significant, why is it being presented and with such prominence (i.e., Figure 1-3).  

Minor Concerns:

1. The phrase “psychological intention” is unusual on p. 2, line 48. The typical phrase used in the field of the “psychological functions of NSSI”.

2. The structure of the introduction could be improved. For example, the transition from discussing the psychological functions of NSSI and perfectionism is a bit jarring. It would read much better if there was a connection between NSSI and perfectionism provided first, rather than introducing the construct in an unrelated fashion to NSSI. Further, the introduction seems to vacillate between discussing NSSI and perfectionism in isolation, demonstrating similarities in NSSI and perfectionism (e.g., both more common among those with elevated self-criticism and emotional dysregulation), and elucidating how perfectionism may be associated with NSSI. For example, on p. 2 line 67, the authors cite a systematic review and state that “maladaptive perfectionism plays also an important role in NSSI engagement” but don’t go on to explain that role. It would be easier to follow if the authors structured the introduction more linearly (e.g., introduce NSSI, discuss general association and similarities with perfectionism, discuss specific mechanisms that may explain the role of perfectionism in the development of NSSI).

3. It is standard practice to provide alpha coefficients for the current sample for all measures included. Further, was inter-rater reliability of the MINI-KID checked in the current sample?  

4. Although the authors articulate two hypotheses clearly in the introduction, different hypotheses are provided in the Regression analysis section (3.2.1). Although I understand that the authors are parsing apart the mediation hypothesis into the specific steps involved in such analyses, it is confusing to refer to a different Hypothesis in the Introduction than in the Results section.

5. The authors refer to Kenny as Kelly on p. 5 line 255.

No major concerns with the quality of the writing in the English language. 

Author Response

REVIEWER 2.

Manuscript ID: ejihpe-2599610

Titel: The Association Between Nonsuicidal Self-injury and Perfectionism in 
Adolescence: The Role of Mental Disorders

The authors provide a comprehensive review of the association between NSSI and perfectionism, building off a previously published systematic review. Using community convenience sample of adolescents in Hungary, the authors examined the mediation of NSSI and perfectionism by mental disorders. Reasonable measures were used to test the hypotheses, with a strength being the use of a structured diagnostic interview. That said, the results are surprising on many levels and raise questions for this reviewer, as articulated below. 

We would like to thank the Reviewer for taking the time to review our manuscript and for the useful comments and suggestions. Please find our answers to each point below.

Major Concerns:

1. The prevalence rates in this sample overshadow the main hypotheses, which are focused on the role of perfectionism and mental disorders (i.e., anxiety), on NSSI engagement and functions. Prevalence rates for NSSI are extremely high for a community sample, higher even than some clinical samples. Further, rates of mental disorders were also exceptionally high, including nearly half of the sample meeting criteria for ASD. Although the authors devote significant text to discussing these unusual findings, given that this was a community sample, I must question the findings. These very high rates raise concern for the validity of the measures used in this study for this population or the representativeness of this convenience community sample, COVID or not. Rates of “suicidality” were also incredibly high, although it is unclear if the authors used the MINI-KID to assess for suicidal ideation or suicidal behavioral as only the term “suicidality” was used. Even relatively uncommon conditions in a community sample, such as psychotic disorders, had prevalence rates of 7-9%. Further, the finding that intrapersonal and interpersonal rates were similarly endorsed in this sample stands in contrast to all studies for which I am aware.

Our research group works in the field of school based adolescent mental health improvement, suicide prevention. Several schools have contacted us where “sensitive” teachers perceived that students might have mental problems. The schools which participated in our study were from this pool, which can contribute to the possible explanation of the high prevalence rates of NSSI and mental disorders. 

This information was added to the Discussion section in line 510-518:

“Our research group works in the field of school-based adolescents mental health improvement, suicide prevention [100,101]. We developed a new school-based mental health promoting prevention program [70] and several schools contacted us to request this prevention program as teachers perceived that students might have mental problems. All participants took part in our study before the prevention program. The high prevalence rates of NSSI and mental disorders derived from this population, and our findings show how much mental health preserving prevention programs are needed in schools. Our results represent the mental state of those high school students, where the sensitive attention of teachers recognised the potential problems.”

This information was added to the Measures section in line 198-215:

“In our study we assessed the suicidal behaviour (suicidal thoughts, plans, attempts) with the MINI-KID. MINI-KID assesses suicidal behaviour very sensitively with several questions related to suicidal thoughts, ideation, plans, attempts. According to the MINI-KID, if a participant answered YES to any of the questions regarding suicidal thoughts, plans, attempts, the case was classified as suicidal behaviour.

The prevalence rates in the current study thus indicate how many adolescents answered YES to any of these questions on thoughts, ideations, plans, attempts on the suicidal behaviour spectrum. The phrase suicidality is used as a synonym for suicidal behavior within Results section.

Each participant received a code number at the start of the study. This code-decode system was used to identify participants if the answers in the MINI-KID structured diagnostic interview indicated the possible presence of an acute suicidal risk. In this case, the participant was immediately contacted by the child- and adolescents psychiatrist member of our team, and a clinical interview was conducted on site to exclude or confirm the presence of an acute suicidal risk. If the acute risk was confirmed, the child-and adolescent psychiatrist specialist from the local health care system contacted the parent/caregiver of the participant by phone to give detailed information about emergency care and the participant was referred to the specialised health care system.”

We mentioned in our Limitation section that: our study should be considered preliminary because of the small sample size and the fact that it was conducted with a Hungarian convenience sample of adolescents, which constricts the generalisability of the results to wider populations.

We mentioned in our Discussion section in line 566-575 that there is a methodological difference between the  our study and previous study which used the original categorisation of NSSI motives regarding the ISAS [21] in which anti-suicide motives belonged to intrapersonal functionality. After the Hungarian adaptation of ISAS [21] was published, we assessed NSSI function according to the ISAS-HU, in which the anti-suicide function belongs to the interpersonal motivation. The anti-suicide function of NSSI serves as coping against suicidal thoughts and attempts [2,19]. More than one third of our community adolescents with a history of NSSI reported suicidal behaviour according to a structured psychiatric interview, so the anti-suicide function may have influenced the results. 

We did additional analysis to this statement. We categorised again the NSSI function according to original categorisation of NSSI motives regarding the ISAS, and our new results confirmed previous results, which emphasised the higher rate of NSSI intrapersonal function.

We modified our manuscript in line 575-585:

“We confirmed it with additional analysis. We categorised again the NSSI function according to the original categorisation of NSSI motives regarding the ISAS [17]. Our additional results confirmed previous studies, which emphasised the higher rate of NSSI intrapersonal function [17,19–21] and the stronger association between NSSI intrapersonal function and maladaptive perfectionism [36,37] (see Table A4-A6 in Appendix). Overall, 95.58 % (n = 65) adolescents who engaged in NSSI (n = 68) reported using the intrapersonal motivation of NSSI, and 85.29% (n = 58) reported using the interpersonal motivation. There was a significant difference related to the prevalence of NSSI functions (intrapersonal, interpersonal), χ2 (1, N = 134) = 77.69, p < .0001. According to this original categorisation of NSSI motives regarding the ISAS [17], our additional findings supported Hypothesis 2.”

We added new table related this statistical analysis in Appendix A section:

Table A4. Associations between perfectionism dimensions and NSSI functions (original ISAS categorisation)

Note. FMPS = Frost Multidimensional Perfectionism Scale; CMD = Concern Over Mistakes and Doubts About Actions subscales; PEC = Parental Expectations and Criticism subscales; PS = Personal Standards subscale; O = Organization subscale; NSSI = nonsuicidal self-injury.

SE – Standard Error, t-Value —T- tests, df- degrees of freedom, p – Level of significance. *p <0.05. **p < 0.01.

Table A5. Associations between perfectionism dimensions and NSSI functions (original ISAS categorisation) after controlling for the effect of mental disorders.

Note. FMPS = Frost Multidimensional Perfectionism Scale; CMD = Concern Over Mistakes and Doubts About Actions subscales; PEC = Parental Expectations and Criticism subscales; PS = Personal Standards subscale; O = Organization subscale; NSSI = nonsuicidal self-injury.

SE – Standard Error, t-Value —T- tests, df- degrees of freedom, p – Level of significance. *p < 0.05. **p < 0.01.

Table A6. Associations between perfectionism dimensions and anxiety disorders.

Note. FMPS = Frost Multidimensional Perfectionism Scale; CMD = Concern Over Mistakes and Doubts About Actions subscales; PEC = Parental Expectations and Criticism subscales; PS = Personal Standards subscale; O = Organization subscale; NSSI = nonsuicidal self-injury.

SE – Standard Error, t-Value —T- tests, df- degrees of freedom, p – Level of significance.

**p < 0.01

2. Given the finding of no difference in association between interpersonal and intrapersonal motivations with perfectionism, and the unusual inclusion of anti-suicide on the interpersonal domain, it is recommended that the authors should consider a sensitivity analysis in which anti-suicide is included on the intrapersonal domain, as it typically found in factor analyses of the ISAS. In the discussion section, the authors suggest that this may be a reason for the findings; however, they are able to test this directly and therefore should consider doing so.

We would like to thank the Reviewer for this suggestion. Please read our answer above.

3. Further, the authors used traditional mediation analysis (i.e., Baron and Kenny), which is generally considered to be inferior to more current causal mediation analysis (see https://doi.org/10.1186/s12874-021-01426-3).

We would like to thank the Reviewer for this question.

A classical mediator model would not be able to test these sort of relationships, only the predefined independent-mediator-dependent variable (DV) paths. Classical mediation analy- sis may easily yield highly biassed results due to omitted variables and model misspecification. On the contrary, psychological networks provide a comprehensive framework to model these sorts of complex interrelationships.

In line 304-309:

“Network modelling provides a test of the potential explanatory mechanism between examined variables. It enables us to show the different pathways between examined variables, how mental disorders, perfectionism dimensions, and NSSI can influence each other in different ways. Network modelling is important in clinical study providing a comprehensive model related to complex interrelationships [88, 89].“

Our results offer preliminary evidence supporting the mediating effect of mental disorders, especially anxiety disorders, on the relationship between maladaptive perfectionism and NSSI engagement, but additional research is necessary to confirm these results with larger samples.

Despite our sample size we wanted to try completing a comprehensive statistical analysis, that is why we used two different statistical analyses. Although the results of network analysis are not significant, findings show the same direction compared to results of regression analysis, that is why we wanted to also represent these data.

4. The inclusion of the network analysis is unclear given that the authors state that they were underpowered and the effects in the network model were not significant.  If not significant, why is it being presented and with such prominence (i.e., Figure 1-3).  

We would like to thank the Reviewer for this suggestion. Please read our answer above.

Minor Concerns:

1. The phrase “psychological intention” is unusual on p. 2, line 48. The typical phrase used in the field of the “psychological functions of NSSI”.

Based on the Reviewer suggestion, we modified the manuscript in line 46:

“NSSI engagement serves several psychological functions, and most individuals use multiple functions [16–19]. Studies focusing on the psychological functions of NSSI support two main factors related to NSSI functionality:”

2. The structure of the introduction could be improved. For example, the transition from discussing the psychological functions of NSSI and perfectionism is a bit jarring. It would read much better if there was a connection between NSSI and perfectionism provided first, rather than introducing the construct in an unrelated fashion to NSSI. Further, the introduction seems to vacillate between discussing NSSI and perfectionism in isolation, demonstrating similarities in NSSI and perfectionism (e.g., both more common among those with elevated self-criticism and emotional dysregulation), and elucidating how perfectionism may be associated with NSSI. For example, on p. 2 line 67, the authors cite a systematic review and state that “maladaptive perfectionism plays also an important role in NSSI engagement” but don’t go on to explain that role. It would be easier to follow if the authors structured the introduction more linearly (e.g., introduce NSSI, discuss general association and similarities with perfectionism, discuss specific mechanisms that may explain the role of perfectionism in the development of NSSI).

We would like to thank the Reviewer for this useful suggestion. We reorganised our Introduction section in line 38-118:

Nonsuicidal self-injury (NSSI), which refers to deliberate self-inflicted harm without suicidal intent [1–3], has become a serious public health concern among adolescents. Although NSSI is a prevalent phenomenon, it remains hidden in many cases [4], and stigmatisation of it is common among adolescents [5]. The lifetime prevalence of NSSI among adolescents ranges from 17.1% to 46.5% in community samples [6–11] and from 51.3% to 82.4% in clinical adolescent populations [12–14]. Moreover, the prevalence of NSSI in adolescents has been on the rise over the past 15 years [4,15].

NSSI engagement serves several psychological functions, and most individuals use multiple functions [16–19]. Studies focusing on the psychological functions of NSSI support two main factors related to NSSI functionality: (1) intrapersonal (e.g., to manage one’s uncomfortable internal state) and (2) interpersonal (e.g., to influence one’s social environment) motivation [20] and suggest that intrapersonal motives are more prevalent and strongly associated with internalising and externalising mental symptoms than are interpersonal motives [17,19–21].

Perfectionism is a potential risk factor for NSSI engagement [22]. It is conceptualised as a multidimensional construct (with intra- and interpersonal aspects) [23,24], and commonly defined as “setting excessively high performance standards, accompanied by overly critical self-evaluations” [23] (p. 450). Factor analytic studies have distinguished two main factors: (1) maladaptive evaluation concerns (maladaptive) and (2) positive achievement striving (adaptive) [25–29]. In recent years, the prevalence rate of maladaptive perfectionism among community adolescents has also reached alarming levels: 22% to -38% [28–32] and, similar to NSSI, perfectionism also is showing an upward tendency [4,15,33,34].

Until now, only a few studies have explored the function of NSSI among perfectionistic adolescents; moreover, some results are inconsistent. Nock and Prinstein (2005) emphasised the role of the social (interpersonal) function of self-injury and found that psychiatric adolescents who perceive unrealistic high expectations from their environment tend to use self-injury to get support from others or to avoid those perceived expectations [35]. Meanwhile, inconsistent with that, Claes et al. (2012) found, among women diagnosed with eating disorders (EDs), patients who perceived parental criticism had a negative relationship with the cry-for-help function of NSSI behaviour [36]. Other findings, with a community adolescent sample [37] and women ED patients [36], have supported the role of the intrapersonal motivation of NSSI related to self-critical perfectionistic concerns. This evidence suggested that unhealthy perfectionistic people tend to use NSSI in order to handle strong negative emotions. Results among perfectionistic people related to NSSI function may be influenced by the age of the study population, and by the mental disorders examined [22].

Related to the possible pathway between two phenomena, few studies have focused on the examination of direct and indirect mechanisms between NSSI and perfectionism, and several aspects remain unclear [22]. Some results indicate a direct relationship between NSSI and perfectionism [36,38,39] and an indirect effect through rumination and negative affect [39]. Gu et al. [8], in a study of community adolescents, found that psychological distress has a mediating effect on the association between the two phenomena. This suggests that there is an indirect relationship between maladaptive perfectionism and NSSI, which is mediated by emotional distress symptoms [8]. It may also imply that NSSI is used as a maladaptive coping strategy to reduce or communicate unwanted emotional states.

Regardless of the fact that the positive perfectionism dimension is characterised by more adaptive outcomes [27], several studies and metanalytic results have indicated that both perfectionism dimensions (adaptive and maladaptive) [32,40–48] and NSSI [12,49–50] have a significant relationship with several internalising and externalising mental disorders. In addition, both phenomena mean risk factor related to suicidal behaviour [6,12,44,51–55]. Maladaptive perfectionism (evaluation concerns) plays an important role in NSSI engagement [22]. Individuals with maladaptive perfectionism and NSSI tend to be highly self-critical [23,56–58], and unhealthy perfectionistic adolescents and individuals with NSSI engagement report similar difficulties in emotion regulation [59,60]. People with maladaptive perfectionism tend to react to failure with elevated levels of shame, guilt, depression, anxiety, and anger [61–63], and these strong negative emotions [61–63] may motivate them to self-harm [64]. These results confirm findings that emphasised that perfectionistic individuals tend to engage in NSSI because of self-punishment, self-torture, and cry-for-help motives [36] and affect regulation and the self-punishment function of NSSI are the most common motivations for this behaviour [2,19], which plays an important role in shame coping [65,66].

Adolescents with history of NSSI rate their family life satisfaction, physical and mental health, and global well-being significantly lower than adolescents without NSSI [12]. Given the high prevalence of NSSI and owing to its significant association with a range of several comorbid internalising and externalising mental disorders [12,49], especially with suicidal behaviour [6,67], NSSI has been recognised as a long-lasting public health problem among adolescents [49,68]. It is critical to explore this behaviour to develop interventions and treatments in order to support those struggling with NSSI engagement [19,69].

Although both NSSI and perfectionism are public health concerns and have a high prevalence rate in the adolescent years, more detailed explorations of NSSI behaviour among community adolescent samples in connection with perfectionism are lacking. Much of the literature has focused on adults, although prevalence rates related to both phenomena are high in the adolescent years. On the basis of the previous literature, little evidence related to perfectionism and NSSI, especially among community adolescent samples, is available, which raises further issues. The primary aim of this study was to replace the missing literature evidence and to explore the relationship between perfectionism dimensions and different NSSI functions, to examine the potential mediating effect of different mental disorders on the relationship between them. Our hypotheses were as follows:

3. It is standard practice to provide alpha coefficients for the current sample for all measures included. Further, was inter-rater reliability of the MINI-KID checked in the current sample?  

As the MINI-KID symptoms are measured with binary items, internal consistency for them was assessed by Kruder-Richardson formula. In general, a score of above 0.5 signals an acceptable level of reliability (KR-20; Kruder & Richardson, 1937).

Kuder, G. F., & Richardson, M. W. (1937). The theory of the estimation of test reliability. Psychometrika, 2(3), 151–160.

We modified our manuscript in line 220-224:

“In our study MINI-KID symptoms were assessed by Kruder-Richardson formula (KR-20). In general, a score of above 0.5 signals an acceptable level of reliability [77]. In our study KR-20 related to mood disorders: 0.45, anxiety disorders: 0.52, substance use disorders: 0.55, attention-disruptive disorders: 0.51, Tic: -0.10, eating disorders: 0.18.”

4. Although the authors articulate two hypotheses clearly in the introduction, different hypotheses are provided in the Regression analysis section (3.2.1). Although I understand that the authors are parsing apart the mediation hypothesis into the specific steps involved in such analyses, it is confusing to refer to a different Hypothesis in the Introduction than in the Results section.

We would like to thank the Reviewer for this suggestion.

We modified the Results section and deleted the different Hypothesis in connection with specific steps of Regression analysis.

5. The authors refer to Kenny as Kelly on p. 5 line 255.

We would like to thank the Reviewer for this comment.

We modified our manuscript in line 299:

We used Baron and Kenny’s three-steps method [87] to show potential mediation effects.

Author Response File: Author Response.pdf

Round 2

Reviewer 1 Report

I want to commend you for your valuable research efforts. Your study sheds light on an important but understudied area, highlighting the significant impact of maladaptive perfectionism on nonsuicidal self-injury (NSSI) among community adolescents. Your findings provide crucial insights into the relationship between perfectionism dimensions, NSSI functions, and the mediating role of anxiety disorders. Your dedication to addressing this growing concern among adolescents is truly commendable and contributes to our understanding of mental health challenges in this population. Keep up the excellent work!

Minor editing of English language required.

Author Response

REVIEWER 1.

I want to commend you for your valuable research efforts. Your study sheds light on an important but understudied area, highlighting the significant impact of maladaptive perfectionism on nonsuicidal self-injury (NSSI) among community adolescents. Your findings provide crucial insights into the relationship between perfectionism dimensions, NSSI functions, and the mediating role of anxiety disorders. Your dedication to addressing this growing concern among adolescents is truly commendable and contributes to our understanding of mental health challenges in this population. Keep up the excellent work!

Minor editing of English language required.

We would like to thank the Reviewer for taking the time to review our manuscript and for the useful comments and suggestions.

After official proofreading which was completed by Poof-Reading-Service.com, we made careful language editing again throughout the whole article.

Author Response File: Author Response.pdf

Reviewer 2 Report

The authors provided a strong response to my concerns from the original manuscript. I appreciate the additional analyses and re-writes that were conducted. I only have two (minor) remaining concerns:

1. The additional information provided about the sample helps to contextualize the prevalence rates of NSSI and SI. I recommend that the authors go a step further in their Limitations section and indicate more clearly that that the sample may have been biased towards more severe mental health concerns given that the participants came from classes in which teachers were concerned about mental health concerns.

2. I appreciate the authors providing the KR-20 results. Given lower reliability for some of the disorders, the authors may want to add some caution in the Limitations sections specifically related to the lower KR-20 results.

The authors may wish to re-write this sentence: "The primary aim of this study was to replace the missing literature evidence and to explore the..." with "The primary aim of this study was to address gaps in the literature by exploring the..." 

Author Response

REVIEWER 2.

The authors provided a strong response to my concerns from the original manuscript. I appreciate the additional analyses and re-writes that were conducted. I only have two (minor) remaining concerns:

We would like to thank the Reviewer for taking the time to review our manuscript and for the useful comments and suggestions.

1. The additional information provided about the sample helps to contextualize the prevalence rates of NSSI and SI. I recommend that the authors go a step further in their Limitations section and indicate more clearly that that the sample may have been biased towards more severe mental health concerns given that the participants came from classes in which teachers were concerned about mental health concerns.
2. I appreciate the authors providing the KR-20 results. Given lower reliability for some of the disorders, the authors may want to add some caution in the Limitations sections specifically related to the lower KR-20 results.

We modified our manuscript and added this information into Limitation section in line 661-668:

“Our findings need to be interpreted in light of the following limitations. Our evidence is based on cross-sectional study design; that is why they do not provide information related to causality. NSSI was assessed as an outcome variable, and we examined its predictors and the association between them. A longitudinal study, focusing on a potential mediating effect, is required to provide evidence for a causal relationship between NSSI and maladaptive perfectionism. We used MINI-KID interview to diagnostic assessment, and it contains questions only related to borderline personality disorder and there are no questions regarding to other forms of personality disorders. According to the instructions of the MINI-KID interview, the ASD diagnoses based on the MINI-KID should be investigated more thoroughly by a licensed child- and adolescent psychiatrist. It did not happen in our study. Related to reliability assessment, MINI-KID symptoms were assessed by KR-20 formula [77], which show lower reliability value (under 0.5) for mood, tic and eating disorders in our study. We used self-report questionnaires for the assessment of perfectionism and NSSI. Our study should be considered preliminary because of the small sample size and the fact that sample may have been biased towards more severe mental health concerns given that the participants came from classes in which teachers were concerned about the mental healthof their students, which constricts the generalisability of the results to wider population.

The authors may wish to re-write this sentence: "The primary aim of this study was to replace the missing literature evidence and to explore the..." with "The primary aim of this study was to address gaps in the literature by exploring the..." 

We would like to thank the Reviewer for this suggestion. We modified our manuscript according it in line 115-118:

“The primary aim of this study was to address gaps in the literature by exploring the relationship between perfectionism dimensions and different NSSI functions, examining the potential mediating effects of different mental disorders on the relationship.”

Author Response File: Author Response.pdf