INVENTORY OF STATEMENTS ABOUT SELF-INJURY (ISAS) – SECTION I. BEHAVIORS | |||||
This questionnaire asks about a variety of self-harm behaviors. Please only endorse a behavior if you have done it intentionally (ie, on purpose) and without suicidal intent (ie, not for suicidal reasons). | |||||
1. Please estimate the number of times in your life you have intentionally (ie, on purpose) performed each type of nonsuicidal self-harm (eg, 0, 10, 100, 500): | |||||
Cutting | ____ | Severe scratching | ____ | ||
Biting | ____ | Banging or hitting self | ____ | ||
Burning | ____ | Interfering with wound healing (eg, picking scabs) | ____ | ||
Carving | ____ | Rubbing skin against rough surface | ____ | ||
Pinching | ____ | Sticking self with needles | ____ | ||
Pulling hair | ____ | Swallowing dangerous substances | ____ | ||
Other _______________ | ____ | ||||
Important: If you have performed one or more of the behaviors listed above, please complete the final part of this questionnaire. If you have not performed any of the behaviors listed above, you are done with this particular questionnaire and should continue to the next. | |||||
2. If you feel that you have a main form of self-harm, please circle the behavior(s) on the first page above that you consider to be your main form of self-harm. | |||||
3. At what age did you: | |||||
First harm yourself? | ____________ | Most recently harm yourself? (approximate date – month/date/year) | ____________ | ||
4. Do you experience physical pain during self-harm? | |||||
Please circle a choice: | YES | SOMETIMES | NO | ||
5. When you self-harm, are you alone? | |||||
Please circle a choice: | YES | SOMETIMES | NO | ||
6. Typically, how much time elapses from the time you have the urge to self-harm until you act on the urge? | |||||
Please circle a choice: | |||||
<1 hour | 1 to 3 hours | 3 to 6 hours | 6 to 12 hours | 12 to 24 hours | >1 day |
7. Do/did you want to stop self-harming? | |||||
Please circle a choice: | YES | NO | |||
INVENTORY OF STATEMENTS ABOUT SELF-INJURY (ISAS) – SECTION II. FUNCTIONS | |||||
Name:_______________ | |||||
Date:________________ | |||||
Instructions This inventory was written to help us better understand the experience of nonsuicidal self-harm. Below is a list of statements that may or may not be relevant to your experience of self-harm. Please identify the statements that are most relevant for you:
| |||||
"When I self-harm, I am ... | Response | ||||
| 0 | 1 | 2 | ||
| 0 | 1 | 2 | ||
| 0 | 1 | 2 | ||
| 0 | 1 | 2 | ||
| 0 | 1 | 2 | ||
| 0 | 1 | 2 | ||
| 0 | 1 | 2 | ||
| 0 | 1 | 2 | ||
| 0 | 1 | 2 | ||
| 0 | 1 | 2 | ||
| 0 | 1 | 2 | ||
| 0 | 1 | 2 | ||
| 0 | 1 | 2 | ||
| 0 | 1 | 2 | ||
| 0 | 1 | 2 | ||
| 0 | 1 | 2 | ||
| 0 | 1 | 2 | ||
| 0 | 1 | 2 | ||
| 0 | 1 | 2 | ||
| 0 | 1 | 2 | ||
| 0 | 1 | 2 | ||
| 0 | 1 | 2 | ||
| 0 | 1 | 2 | ||
| 0 | 1 | 2 | ||
| 0 | 1 | 2 | ||
| 0 | 1 | 2 | ||
| 0 | 1 | 2 | ||
| 0 | 1 | 2 | ||
| 0 | 1 | 2 | ||
| 0 | 1 | 2 | ||
| 0 | 1 | 2 | ||
| 0 | 1 | 2 | ||
| 0 | 1 | 2 | ||
| 0 | 1 | 2 | ||
| 0 | 1 | 2 | ||
| 0 | 1 | 2 | ||
| 0 | 1 | 2 | ||
| 0 | 1 | 2 | ||
| 0 | 1 | 2 | ||
(Optional) In the space below, please list any statements that you feel would be more accurate for you than the ones listed above: | |||||
| |||||
(Optional) In the space below, please list any statements you feel should be added to the above list, even if they do not necessarily apply to you: | |||||
| |||||
ITEMS COMPRISING EACH OF 13 FUNCTIONS SCALES | |||||
Affect regulation – 1, 14, 27 | |||||
Interpersonal boundaries – 2, 15, 28 | |||||
Self-punishment – 3, 16, 29 | |||||
Self-care – 4, 17, 30 | |||||
Anti-dissociation/feeling-generation – 5, 18, 31 | |||||
Anti-suicide – 6, 19, 32 | |||||
Sensation-seeking – 7, 20, 33 | |||||
Peer-bonding – 8, 21, 34 | |||||
Interpersonal influence – 9, 22, 35 | |||||
Toughness – 10, 23, 36 | |||||
Marking distress – 11, 24, 37 | |||||
Revenge – 12, 25, 38 | |||||
Autonomy – 13, 26, 39 | |||||
Scores for each of the 13 functions range from 0 to 6. |
Do you want to add Medilib to your home screen?