Latent profiles of coping styles and their associations with non-suicidal self-injury in adolescents with social anxiety disorder

Social anxiety disorder (SAD) is prevalent among adolescents, with rates ranging from 2.6–10.6% [1, 2], leading to immediate challenges in social interactions like avoiding social situations and long-term struggles in forming relationships, academic performance, and overall functioning [3, 4]. SAD manifests as excessive fear or avoidance of social interactions and situations involving possible scrutiny [5]. Individuals with SAD encounter elevated levels of interpersonal stress [6], which can trigger dangerous behaviors such as non-suicidal self-injury (NSSI) [7, 8]. NSSI is defined as the direct, deliberate destruction of one’s body tissue without suicidal intent [9]. NSSI is correlated with the exacerbation of mental health disorders in adolescents, including increased anxiety and higher risk of future suicide attempts [10, 11]. In clinical samples, individuals with anxiety disorders have 1.76 times the odds of engaging in NSSI compared to those without this diagnosis [12]. SAD is a common comorbid diagnosis for NSSI [13]. The prevalence of NSSI among adults with SAD is 32.64% [14], and 37.5% of adults diagnosed with NSSI disorder according to DSM-5 criteria also have SAD [15]. Although studies on adolescents are limited, one study found that 38.5% of female adolescents who meet the DSM-5 criteria for NSSI disorder also have SAD [13]. Recent research indicates that social anxiety significantly elevates the risk of NSSI among middle school and high school adolescents [16, 17]. Therefore, NSSI in adolescents with SAD is a pressing concern that requires immediate attention.

Furthermore, NSSI may adversely affect the efficacy of treatment for SAD. Individuals with SAD often exhibit distortions and biases in processing social and evaluative information [18]. Cognitive behavioral therapy (CBT) is the first-line intervention for SAD in children and adolescents [19], aiming to address cognitive distortions and avoidance of social situations through techniques such as experiential exercises, graduated exposure, and cognitive restructuring. However, approximately 30–50% of adolescents with SAD do not derive sufficient benefit from CBT [20, 21]. Clinical observations indicate that adolescents with SAD who also engage in NSSI often exhibit diminished treatment efficacy. Although research on the impact of NSSI on treatment outcomes for adolescents with SAD is limited, existing studies suggest that NSSI attenuates the effectiveness of CBT for depression in adolescents [22, 23]. Therefore, it is essential to identify specific subgroups of adolescents with SAD who are particularly predisposed to engaging in NSSI. This insight is critical for refining treatment strategies and improving therapeutic efficacy for SAD with NSSI.

There is heterogeneity in the tendency for NSSI among adolescents with SAD. For instance, one study identified two distinct temperament subgroups among university students with SAD, revealing that the impulsive group had twice the occurrence of a history of suicide, suicide attempts, and self-harm compared to the inhibited group [24]. The way individuals cope with psychological distress plays a critical role in determining their predispositions to NSSI. Coping style, defined as the emotional and behavioral responses to internal and external demands in stressful situations [25], can be divided into problem-focused coping and emotion-focused coping. Problem-focused coping refers to strategies aimed at managing or changing the problem that is causing distress, while emotion-focused coping involves strategies designed to regulate the emotional responses associated with the problem [25]. Coping is a critical factor in propensities to NSSI [26, 27]. Nock’s integrated theoretical model proposes that individuals may engage in NSSI when they struggle to cope with stress and emotional reactions [28]. Additionally, existing research suggests a bidirectional relationship between coping strategies and social anxiety in adolescents may have a bidirectional effect [29]. More reliance on emotion-focused coping and less reliance on problem-focused strategies may exacerbate social anxiety symptoms [30, 31]. On the other hand, individuals with higher levels of social anxiety are more likely to employ emotion-focused coping strategies [32], which may increase the risk of NSSI among adolescents with SAD. Therefore, exploring the heterogeneity of coping styles among adolescents with SAD can help identify subgroups at higher risk for NSSI.

Emotion-focused coping strategies have been associated with an elevated risk of NSSI [33, 34]. However, the relationship between problem-focused coping and NSSI is less clear. Some studies have found adolescents who adopt problem-focused coping strategies are less susceptible to engaging in NSSI [35, 36]. Other research findings have not consistently supported this correlation [37‐39]. Literature from 2000 to 2010 reveals conflicting findings on the relationship between problem-focused coping and deliberate self-harm in teenagers [37].One plausible hypothesis for these divergent results is that there may be variations in coping strategies and their association with NSSI among adolescents. Previous research often focused on the relationship between coping strategies and NSSI behaviors through a variable-centered approach, potentially oversimplifying the complexity of coping styles among adolescents. Moreover, there is a lack of research investigating the socio-demographic predictors of these coping profiles among adolescents with SAD, a critical aspect for identifying at-risk individuals for targeted interventions. This gap highlights the need for a more refined analysis that captures the heterogeneity of coping strategies in adolescents with SAD and their implications for NSSI behaviors.

Person-centered analysis offers a promising avenue for investigating heterogeneity within a group. It is a modeling approach that divides individuals into different subgroups based on common response patterns [40], allowing for the examination of different coping patterns in adolescents with SAD. Latent profile analysis (LPA) is one of the most commonly used methods and is considered to be more refined and effective than traditional classification methods [41]. Several studies have employed LPA to explore the coping patterns of adolescents, classifying individuals into different latent profiles based on their response patterns to coping styles and thereby providing novel insights into the relationship between coping patterns and individuals’ mental health status [42, 43].

Therefore, this study aims to explore the latent profile of coping styles in adolescents with SAD using LPA. Additionally, this study seeks to examine the connection between coping strategies and NSSI behaviors from a person-centered standpoint. Furthermore, the study aims to identify the socio-demographic factors that predict membership in the latent coping profile. These findings may serve as a valuable resource for promptly identifying and developing customized clinical interventions for adolescents who are at a heightened risk of NSSI.

This research investigated the coping profiles of adolescents with SAD, identifying two distinct groups: the high problem-focused coping group and the low problem-focused coping group. The findings revealed notable differences in their vulnerability to engaging in NSSI. Adolescents with SAD in the high problem-focused group displayed a lower frequency of NSSI behaviors in the past month, six months, and one year compared to those in the low problem-focused coping group, with nearly equal distribution among the participants in the sample. Furthermore, among adolescents with SAD, older age was associated with a significantly lower likelihood of being classified into the low problem-focused coping group. The findings of this study indicate that the adoption of problem-focused coping strategies significantly influences the susceptibility to NSSI among adolescents with SAD. This work expands upon previous research and proposes that problem-focused coping acts as a protective factor against NSSI in adolescents with SAD [33, 35, 36]. Previous studies have shown that limited access to emotion regulation strategies has a medium-to-large association with NSSI [59]. NSSI is believed to serve the purpose of assisting individuals in handling severe distress when their current coping mechanisms are inadequate for dealing with challenging circumstances [28, 60]. The findings of a study employing a daily diary revealed a positive correlation between problem-focused coping strategies and improved ability to resist transient thoughts and strong urges of NSSI [61]. Therefore, a possible explanation of our findings is that adolescents with SAD in the low problem-focused group may turn to NSSI as a way to alleviate intense emotional pain, because their coping strategies do not effectively manage stressful circumstances [62]. On the other hand, adolescents with SAD who have a strong inclination towards problem-focused coping tend to adopt coping strategies such as problem-solving, seeking social support, and positive rationalizations. These coping strategies enhance their ability to resist NSSI. While the effectiveness of these coping strategies in adolescents with SAD has not been thoroughly examined, current research suggests that they effectively reduce the impact of stressful events and decrease negative emotions [63, 64], thereby potentially reducing NSSI.

It should be acknowledged that the effectiveness of coping strategies may not uniformly apply to behaviors observed more than one year ago. Although adolescents with SAD in the high problem-focused coping group exhibited fewer NSSI behaviors more than one year ago compared to the low problem-focused coping group, the difference did not reach statistical significance. The lack of statistically significant difference may be attributed to recall bias, which increases as the recall period lengthens. A previous study found that recall bias significantly impacts the estimation of annual injury rates in adolescents, with rates decreasing from 24.4 per 100 for a 1-month recall period to 14.7 per 100 for a 12-month recall period [65]. Additionally, some studies failed to find a consistent association between problem-focused coping and NSSI [37‐39]. For instance, a study conducted on adolescents in inpatient care showed problem-focused coping did not moderate the relationship between deficits in emotion expression and NSSI [39]. The disparity in these findings may be partly due to the absence of prior investigations on adolescents with SAD as well as differences in sample characteristics. Alternatively, there may be additional variables influencing the association between coping strategies and NSSI among adolescents diagnosed with SAD that were not considered in this study.

This study further investigated the factors that predict latent coping membership, specifically analyzing the impact of socio-demographic characteristics and levels of anxiety. Age was found to be a significant predictor of the latent coping membership, with older age associated with a higher likelihood of being categorized into the high problem-focused coping group. Prior studies have indicated variations in the development of coping strategies between children and adolescents, suggesting that problem-focused coping skills tend to increase during adolescence [66, 67]. Our findings highlight the significance of directing attention and providing support to younger adolescents with SAD who may still be in the process of developing effective problem-focused coping strategies. A lack of problem-solving capacity is a risk factor for the onset and persistence of NSSI into adulthood [68]. Hence, it is imperative to prioritize educating younger adolescents to help them develop problem-oriented coping strategies. Initiatives aimed at enhancing problem-solving skills in children and adolescents, such as problem-solving therapy, have demonstrated effectiveness in improving depression and reducing suicide risk among adolescents [69, 70]. This suggests that enhancing adolescents’ problem-focused coping strategies may improve their ability to solve practical problems and holds the potential for reducing NSSI among adolescents. This approach may also be applicable to younger adolescents. In an intervention study involving children aged 9 to 12 with depression, problem-solving therapy was shown to significantly reduce depressive symptoms [71].

NSSI behaviors of adolescents are closely intertwined with their physical and mental health and have long been a critical public health concern. The results of this study provide significant insights for clinical interventions, emphasizing the need to target adolescents with SAD who are at risk of NSSI. Existing research highlights the importance of planning, active coping, positive reinterpretation, and acceptance in developing strategies to manage social anxiety and NSSI; on the other hand, a lack of these strategies increases the risk of social anxiety and NSSI among adolescents [27, 29, 31]. These findings suggest that future clinical interventions should prioritize educating adolescents on problem-focused coping strategies, such as problem-solving, seeking social support, and positive rationalization, to help them manage challenges and reduce emotional distress. These skills are particularly crucial for adolescents with SAD, who often avoid social interactions due to heightened anxiety, thus encountering greater challenges in seeking support from others [72]. Future interventions should provide more problem-solving training for adolescents with SAD who exhibit low levels of problem-focused coping to help reduce their risk of self-harm. This approach aligns with empirical research showing positive responses to problem-solving therapies in interventions targeting NSSI [73].

This study makes several contributions. Firstly, it identified specific groups of coping strategies and reveals patterns of coping styles among adolescents with SAD. Furthermore, it focuses specifically on NSSI behaviors in adolescents with SAD, demonstrating notable differences in NSSI behaviors between the high and low problem-focused groups. This provides valuable information for identifying adolescents at higher risk for NSSI and tailoring clinical interventions accordingly.

Despite its insights, this study is not without limitations. The cross-sectional design restricts causal inferences, necessitating longitudinal studies to elucidate the temporal relationship between coping styles and NSSI. Additionally, the use of self-reported measures may introduce bias, highlighting the need for multi-method approaches in future research. Lastly, the participants were recruited from outpatient clinics in Shanghai, with twice as many females as males. This gender imbalance mirrors the higher prevalence of SAD among females in adolescent populations [74]. Additionally, to ensure the reliability of our findings, we excluded questionnaires with more than 10% missing data. While this approach ensured data quality, it may limit the representativeness and generalizability of our results. Therefore, caution should be exercised when extrapolating the results to broader populations. Future studies should also explore intervention strategies that promote problem-focused coping, potentially mitigating the risk of NSSI in this vulnerable population.

This research examined the coping profiles of adolescents with SAD, identifying high and low problem-focused coping groups. Adolescents in the high problem-focused group had a lower frequency of NSSI over the past month, six months, and one year compared to those in the low problem-focused group. Older adolescents with SAD were less likely to be classified into the low problem-focused coping group. The findings indicate that adolescents with SAD who use fewer problem-focused coping strategies are at higher risk of NSSI. These results highlight the need for interventions promoting problem-focused coping to enhance problem-solving skills and improve physical and mental health in adolescents with SAD.