Validation of the Non-Suicidal Self-Injury Scar Cognition Scale in a Russian-Speaking Sample

Grigoreva, A.A. I.M. Sechenov First Moscow State Medical University, Moscow, Russia Ryazan State Medical University named after I.P. Pavlov, Ryazan, Russia

Kondratovich, A.K. I.M. Sechenov First Moscow State Medical University, Moscow, Russia

Trabelsi, F.M. Ryazan State Medical University named after I.P. Pavlov, Ryazan, Russia

Mokritskaya, A.N. I.M. Sechenov First Moscow State Medical University, Moscow, Russia

Marachev, M.P. Neurocentre of medical-psychological correction and rehabilitation, Moscow, Russia

Fedotov, I.A. Ryazan State Medical University named after I.P. Pavlov, Ryazan, Russia

Introduction

Non-suicidal self-injury (NSSI) is a prevalent form of self-directed aggression that remains a significant public health concern, prompting a substantial increase in research over recent decades (Duarte et al., 2020; Gardner et al., 2021). Epidemiological studies indicate that 17% to 36% of individuals in the general population engage in NSSI (Kiekens et al., 2023; Nock et al., 2006; Polskaya, 2017), with prevalence rates rising to 40%–61% in clinical samples (Akselrov et al., 2021; Daryin & Zaitseva, 2023; Zinchuk et al., 2019). This behavior is associated with a wide spectrum of mental health problems, adversely affecting both immediate functioning and long-term prognosis (Akselrov et al., 2021; Nock et al., 2006).

The scarring that results from NSSI represents a significant physical and psychological consequence. These scars often have a more detrimental impact on body image than those from accidental injuries or surgeries (Dyer et al., 2013; Ho et al., 2018). For many, scars act as potent triggers, reactivating the negative memories and psychological distress that precipitated the self-injurious act (Bachtelle & Pepper, 2015; Burke et al., 2017). Research indicates that scars carry a distinct emotional significance; for instance, one study found that 65% of individuals with NSSI perceive their scars negatively, associating them with personal failures and regrets (Foley, 2022). Negative experiences such as social stigmatization, shame, guilt, and regret often drive individuals to seek surgical or cosmetic treatments to enhance the social acceptability of their scars (Edriss et al., 2022; Ho et al., 2018; Linington, 2024; Takaya et al., 2020). Conversely, a parallel body of evidence suggests that some individuals perceive their self-injury scars positively, viewing them as marks of personal strength and survival (Kendall et al., 2021; Linington, 2024). This interpretation of scars can have a positive effect on psychotherapeutic work.

Consequently, the cognitive appraisal of NSSI scars is a complex and multifaceted phenomenon that necessitates reliable assessment tools. To address this gap, Burke et al. (2017) developed the Non-Suicidal Self-Injury Scar Cognition Scale (NSSI-SCS), The original English version of the NSSI-SCS is a 26-item self-report questionnaire that assesses scar-related cognitions over the preceding two weeks. It measures five distinct types of appraisals: (1) Reminder Cognitions (scars reactivating memories and emotions linked to the self-injury), (2) Social Cognitions (scars as a source of social stigma and judgment), (3) Weak Cognitions (scars associated with shame, unattractiveness, and weakness), (4) Suicide Cognitions (scars provoking suicidal thoughts), and (5) Positive Cognitions (scars viewed as symbols of resilience and overcoming hardship). At the time of our study, the scale had no validated translations and was available only in English.

While several psychometric instruments available in Russian research practice address various aspects of NSSI – such as the experiences during the act itself (e.g., ISAS I; Kibitov et al., 2025), its functions (e.g., ISAS II; Kibitov et al., 2025; Zinchuk et al., 2023), motivations (e.g., Scale of Reasons for Self-Injurious Behavior; Polskaya, 2014), and the severity of harm (e.g., The Deliberate Self-Harm Inventory; Kuznetsova et al., 2021) – none specifically target the cognitive and emotional consequences of the resulting scars. Therefore, validating the NSSI-SCS within the Russian cultural context is crucial to address this methodological gap. A culturally adapted version would provide researchers and clinicians with a vital tool for assessing attitudes toward NSSI scars, which is essential for understanding their long-term consequences and developing targeted interventions. The aim of the present study was to adapt and validate the Russian-language version of the NSSI-SCS in a sample of individuals with a history of non-suicidal self-injury.

NSSI-SCS overview

The systematic study of cognitive appraisals of non-suicidal self-injury (NSSI) scars was preceded by qualitative explorations and preliminary quantitative evaluations attempts. Early conceptualization efforts include the work of Lewis & Mehrabkhani (2016), who conducted a thematic analysis of online forum discussions where individuals shared experiences with self-injury scars. They identified key themes in scar appraisal, including shame, embarrassment, reminders of past pain, and the perception of scars as symbols of survival and strength. These themes laid the groundwork for future conceptual domains of the NSSI-SCS. Among the first attempts to create a quantitative scale were the studies by Bachtelle & Pepper (2015), who developed measures for shame and personal growth related to scars. However, their instruments were limited by a small number of items, the absence of factor analysis for validation, and a dichotomous response format, which prevented a full exploration of the complex experiences associated with scarring. Another instrument, the Non-Suicidal Self-Injury Assessment Tool (NSSI-AT) by Whitlock et al. (2014), included items on scars, but the reliability of the relevant subscale was low. Thus, by 2017, while a qualitative understanding of the phenomenon existed, quantitative measurement attempts were fragmented and unreliable. There was no unified, psychometrically sound tool to comprehensively assess the diverse cognitions about scars. The Burke et al. (2017) NSSI-SCS systematizing previous findings into a single, valid scale.

The original English version of the NSSI-SCS was designed as a comprehensive self-report instrument to assess the wide spectrum of thoughts and beliefs individuals associate with their NSSI scars. Item development was based on previous research, early scale development attempts, and existing theoretical models concerning NSSI, suicidal behavior, and psychotrauma. The scale's core premise is that NSSI scars are not merely physical remnants but potent stimuli imbued with significant psychological meaning, which can influence ongoing distress, self-perception, and clinical outcomes. Crucially, understanding these appraisals is essential for identifying potential therapeutic targets for patients with different experiences in connection with NSSI.

Initially, Burke generated a 26-item questionnaire distributed across four hypothesized domains: Reminder Cognitions, Social Cognitions, Suicide Cognitions, and Positive Cognitions. A fifth domain, Weak Cognitions, was not initially planned but emerged from empirical data. An Exploratory Factor Analysis (EFA) on a sample of 110 students with NSSI scars revealed this distinct factor, which was subsequently interpreted post-hoc. Consequently, the final five-factor model (Reminder, Social, Suicide, Positive, Weak) resulted from a combination of theoretical groundwork, qualitative data, and empirical validation. 

SCS-Reminder Cognitions (Items 3, 4, 9, 15). This subscale assesses the extent to which an individual's NSSI scars serve as persistent and intrusive reminders of past negative experiences, failures, and stressful life events. Conceptually, the scars are appraised as cues that trigger aversive memories related to the circumstances that originally prompted the self-injurious behavior. This is grounded in trauma theory, which posits that permanent physical markers can act as constant retrievers of painful memories, thereby potentially maintaining or exacerbating psychological distress (Weaver et al., 2007). Representative Items: “My scar(s) bring back memories of things that I don’t want to remember,” “My scar(s) remind me of stressful things that happened to me in the past.”

SCS-Social Cognitions (Items 8, 10, 16, 18, 23). This subscale measures cognitions related to the perceived social stigma and interpersonal consequences of having visible NSSI scars. It captures a dual-layered experience: (1) the external component of perceived stigma, including the belief that others judge, stare, or are embarrassed by one's scars, and (2) the internalized component, where this anticipated social judgment fuels profound feelings of personal shame. This dimension is supported by literature on the stigma associated with mental illness, where scars are often perceived as physical manifestations of a disorder (Hodgson, 2004; Lewis & Mehrabkhani, 2015). Representative Items: “My scar(s) make me embarrassed in front of other people,” “I think that people judge me because of my scar(s).”

SCS-Suicide Cognitions (Items 14, 17, 19, 22, 25, 26). This subscale measures the cognitive linkage between NSSI scars and suicidal ideation and capability. It encompasses two key components derived from the Interpersonal-Psychological Theory of Suicide (IPTS; Van Orden, 2008): (a) scars fostering feelings of hopelessness and entrapment, which fuel suicidal desire, and (b) scars contributing to an acquired capability for suicide by reducing the fear of death and increasing the perceived competence to enact lethal self-harm. Representative Items: “My scar(s) make me feel hopeless,” “My scar(s) make me feel less afraid of dying.”

SCS-Positive Cognitions (Items 1, 2, 5, 11, 20). In contrast to the negative domains, this subscale captures positively valenced interpretations of NSSI scars, measuring appraisals of scars as symbols of personal strength, resilience, and survival. Cognitions here include viewing scars as a source of pride, hope, and evidence of having overcome significant adversity (Bachtelle & Pepper, 2015; Kendall et al., 2021; Lewis & Mehrabkhani, 2015;). Representative Items: “My scar(s) represent how strong I am emotionally,” “My scar(s) represent how strong I am physically.”

SCS-Weak Cognitions (Items 6, 7, 12). This subscale reflects a self-perception of inherent weakness and vulnerability intrinsically linked to the scars. While Reminder Cognitions focus on the scars' function as triggers for external memories of past events, Weak Cognitions are directed inward, representing a global, negative self-evaluation in the present. They encompass feelings of fear and the belief that the scars are a testament to one’s core inadequacy and inability to cope. Representative Items: “My scar(s) remind me that I am weak,” “My scar(s) make me feel afraid.”

In summary, the NSSI-SCS provides a nuanced, multidimensional framework for understanding how individuals cognitively process their self-injury scars. Its five subscales illuminate the complex and often contradictory ways scars can be perceived—as sources of social shame, painful reminders, self-perceived weakness, catalysts for suicidal thinking, and, importantly, personal strength. This comprehensive assessment offers a critical tool for both research into the long-term psychological impact of NSSI, which makes it possible to use this information in formulating a clinical prognosis and choosing a method of influencing symptoms.

Methods 

Participants 

The study sample comprised outpatient and inpatient individuals aged 18 to 70 who sought specialized psychiatric care and presented with at least one visible NSSI-related scar, as confirmed by self-report or corroboration from relatives. Participants were recruited via a consecutive sampling method from the clinical departments of the N.N. Bazhenov Regional Clinical Psychiatric Hospital (Ryazan) and the private outpatient neuropsychiatric clinic "Neurocenter" (Moscow) between November 2023 and January 2025. The sample size was determined a priori based on the psychometric standard of 10 participants per scale item (Nunnally, 1978).

Inclusion Criteria were: 1) age 18–70 years; 2) presence of at least one scar confirmed to result from NSSI; 3) a primary ICD-10 diagnosis of Mood (Affective) Disorders (F30-F39), Neurotic, Stress-related, and Somatoform Disorders (F40-F48), Behavioural Syndromes associated with Physiological Disturbances (F50-F59), or Disorders of Adult Personality and Behaviour (F60-F69); and 4) provision of written informed consent.

Exclusion Criteria included: 1) a documented history of Organic Mental Disorders (F00-F09), Substance Use Disorders (F10-F19), Schizophrenia Spectrum Disorders (F20-F29), or Intellectual Disabilities (F70-F79); and 2) a current psychotic episode, acute intoxication, catatonia, or significant cognitive impairment as assessed through clinical examination and medical record review.

The initial screening identified 329 eligible individuals aged 18 to 53 years (M = 23.3, SD = 5.385). From this cohort, 262 respondents who provided complete datasets and fully met the inclusion criteria constituted the final analytical sample.

The final sample was predominantly female (74.4%), with 19.8% male and 5.7% not reporting gender. The most frequent educational attainment was incomplete higher education (30.5%), followed by secondary vocational (26.3%) and higher education (21.7%). Most participants were single (52.7%), and 34.3% were employed at the time of the assessment (see Table 1 for detailed sociodemographic and clinical characteristics).

Table 1

Clinical and Sociodemographic characteristics of the sample

Characteristics	M (SD)\N (%)
Age	23.5 (5.385)
Gender
Male	52 (19.8%)
Female	195 (74.4%)
Not reported	15 (5.7%)
Education
Primary school education	13 (4.9%)
Secondary school education	43 (16.4%)
Vocational secondary education	69 (26.3%)
Higher education	57 (21.7%)
Incomplete higher education	80 (30.5%)
Occupation
Employed	90 (34.3%)
Studying	76 (29%)
Employed and studying	46 (17.5%)
Unemployed and not studying	50 (19.1%)
Marital status
Married	28 (10.7%)
Single	138 (52.7%)
Cohabitation	45 (17.2%)
In a relationship (not cohabiting)	45 (17.2%)
Divorced	6 (2.3%)
Psychiatric diagnosis
F40-48 Neurotic, Stress-related, and Somatoform Disorders	142 (54.2%)
F60-69 Disorders of Adult Personality and Behaviour	21 (8%)
F30-39 Mood [Affective] Disorders	99 (37.8%)

The majority of participants (54.2%) were diagnosed with disorders from ICD-10 block F40-F48 (Neurotic, stress-related, and somatoform disorders). Affective disorders (F30-F39) constituted the second most prevalent diagnostic category (37.8%), while disorders of adult personality and behaviour (F60-F69) were less frequent (8%).

Procedure

The adaptation and validation process commenced with obtaining official authorization from the original author of the NSSI-SCS, Professor Taylor Burke. A comprehensive validation protocol was subsequently implemented, comprising the following sequential stages: (a) forward-back-translation and cross-cultural adaptation; (b) assessment of sampling adequacy and evaluation of internal consistency reliability; (c) confirmatory factor analysis (CFA) to test the original model's fit; (d) exploratory factor analysis (EFA) using Principal Component Analysis with Oblimin rotation to investigate the underlying factor structure; and (e) examination of convergent and discriminant validity through correlation analyses with established psychological measures.

The translation and cross-cultural adaptation of the NSSI-SCS items were conducted by a panel of three bilingual experts (two psychiatrists and one clinical psychologist). The expert group reviewed and approved the final Russian version after reconciling the back-translated text with the original. This version was piloted on a sample of 30 individuals with a history of NSSI; no participants reported difficulties in comprehending the instructions or item content.

Data Collection

Data were collected in a single session. Eligible participants, identified through consecutive sampling, received full disclosure of the study's purposes and provided written informed consent. The testing procedure began with a sociodemographic and clinical questionnaire, which included a critical screening item: "Do you have any scars from self-injury?" Response options were: 1) Yes, in visible areas; 2) Yes, in concealed areas; 3) No. This item, informed by Burke et al. (2017) on the clinical relevance of scar visibility, screened out individuals without scars and documented scar location. Participants then completed a battery of six self-report measures, selected for their theoretical alignment with the cognitive appraisals measured by the NSSI-SCS.

Instruments of Measurement

1. Non-Suicidal Self-Injury Scar Cognition Scale (NSSI-SCS). The NSSI-SCS is designed to assess cognitive and emotional responses to self-injury scars. The 26-item scale measures five domains of scar appraisal: Reminder Cognitions, Social Cognitions, Weak Cognitions, Suicide Cognitions, and Positive Cognitions. Respondents rate items on a 5-point Likert scale from 1 ("Not at all") to 5 ("Extremely").

2. Ruminative Responses Scale (RRS; Pugovkina et al., 2021). This scale assesses a ruminative cognitive style, characterized by a passive, repetitive focus on negative emotions. It was selected to evaluate convergent validity with the "Reminder Cognitions" subscale, based on the premise that scars acting as reminders of distress would correlate with a general tendency toward rumination.

3. Liebowitz Social Anxiety Scale (LSAS; Grigorieva & Enikolopov, 2016). The LSAS measures social anxiety through fear and avoidance subscales. It was paired with the "Social Cognitions" subscale, as cognitions of social stigmatization and embarrassment related to scars are a direct manifestation of social anxiety.

4. Inventory of Statements about Self-Injury (ISAS-II; Zinchuk et al., 2023). The ISAS-II assesses interpersonal and intrapersonal functions of NSSI. It was used to examine the relationship with the "Positive Cognitions" subscale, hypothesizing that appraising scars as a symbol of inner strength would be linked to specific self-injury functions (e.g., affect regulation, autonomy).

5. Situational Inventory of Body-Image Dysphoria (SIBID; Baranskaya et al., 2008). The SIBID measures context-specific body-image distress. It was aligned with the "Weak Cognitions" subscale, as cognitions of physical flaw and weakness associated with scars were expected to correlate with general body-image dysphoria.

6. Beck Scale for Suicide Ideation (BSSI; Beck et al., 1979). This scale quantifies the intensity of suicidal intent. It was correlated with the "Suicide Cognitions" subscale, testing the critical hypothesis that scar-related suicidal ideation would show a strong association with a standardized measure of suicidality.

In the present study, Cronbach's alpha and McDonald's Omega Coefficients for each tool were also calculated (see Table 2). 

Table 2

Internal Consistency Reliability of the Study Measures: Cronbach's Alpha and McDonald's Omega Coefficients

Scales	Cronbach's α	McDonald’s ω
Liebowitz Social Anxiety Scale	.900	.920
Inventory of Statements about Self-Injury, ISAS-II	.781	.798
Ruminative Responses Scale	.803	.858
Beck Scale for Suicide Ideation	.875	.877
Situational Inventory of Body-Image Dysphoria	.956	.957

Furthermore, a supplemental item evaluating scar location was included in the assessment protocol. This inclusion is clinically justified, as the visibility of scars can exacerbate self- and social stigma and may act as a situational trigger for maladaptive self-regulation by reactivating distressing memories (Burke et al., 2017). 

Data Analysis

Statistical analyses were performed using Microsoft Excel 2013 and Jamovi version 2.3.21. Prior to conducting the main analyses, the normality of the data distribution was assessed using the Shapiro-Wilk test. Since the data significantly deviated from a normal distribution, non-parametric statistical methods were employed for all subsequent analyses.

The suitability of the data for factor analysis was evaluated using the Kaiser-Meyer-Olkin (KMO) measure of sampling adequacy and Bartlett's test of sphericity. The high KMO value and the significant result of Bartlett's test confirmed the adequacy of the sample and the presence of sufficient inter-item correlations to proceed with factor analysis.

To examine the factorial structure of the questionnaire, both Exploratory Factor Analysis (EFA) and Confirmatory Factor Analysis (CFA) were conducted. Principal Component Analysis (PCA) with Oblimin rotation was used for the EFA. Items were retained if they exhibited a minimum factor loading of .5 on their primary factor. The CFA was performed to verify the original five-factor model proposed by the scale's authors. Model fit was assessed using multiple indices: the Chi-square statistic (χ²), the Comparative Fit Index (CFI), the Tucker-Lewis Index (TLI), the Root Mean Square Error of Approximation (RMSEA) with its 90% confidence interval, and the Standardized Root Mean Square Residual (SRMR). Standard thresholds for acceptable model fit were applied (CFI/TLI > .90, RMSEA < .08, SRMR < .08). The Chi-Square Difference Test was used for direct model comparison.

The internal consistency reliability of the scale and its subscales was evaluated using both Cronbach’s (α) and McDonald's (ω). Convergent and discriminant validity were assessed by examining bivariate correlations between the NSSI-SCS subscales and scores from established external measures, including the Beck Scale for Suicide Ideation (BSSI), the Liebowitz Social Anxiety Scale (LSAS), the Ruminative Responses Scale (RRS), and the Situational Inventory of Body-Image Dysphoria (SIBID). Spearman's rank correlation coefficient (ρ, rho) was used for these analyses due to the non-normal data distribution.

To investigate differences in NSSI-SCS scores based on scar location (visible vs. hidden), the non-parametric Mann-Whitney U test was employed. For all statistical tests, a two-tailed p-value p≤.05 was considered statistically significant.

In addition to the correlation analyses, a quartile comparison was conducted to further examine the scale's validity and its ability to discriminate between respondents with polarized scores. Participants scoring in the highest (Q4) and lowest (Q1) quartiles on each NSSI-SCS subscale were compared using the Mann-Whitney U test. This analysis serves to complement the correlation analysis by not only establishing linear relationships but also quantifying the magnitude of differences between groups with minimal versus maximal levels of scar-related cognitions across key clinical and functional variables. This approach provides robust evidence for the discriminative validity of the subscales.

Results

Internal consistency and structural validity

At the initial stage of statistical analysis, the suitability of the data for factor analysis was assessed. The Kaiser-Meyer-Olkin measure of sampling adequacy yielded a value of .866, and Bartlett’s test of sphericity was statistically significant (χ² = 2691, df = 210, p < .001). These results confirmed that the data contained a sufficient number of meaningful intercorrelations to proceed with factor analysis. To verify the original five-factor structure of the NSSI-SCS in the Russian-speaking clinical sample, a confirmatory factor analysis (CFA) was conducted (see Table 3).

Table 3

Model Fit Indices for the Confirmatory Factor Analysis (CFA) of the Original NSSI-SCS Five-Factor Structure

Factor	NSSI-SCS Statement	Factor Loading	SE	Z	p	Std. Loading
1 Reminder Cognitions	3.My scars bring back memories of things that I don’t want to remember	.8012	.085	9.394	< .001	.6072
	9. My scars remind me of stressful things that happened to me in the past	.7729	.081	9.507	< .001	.605
	15. My scars make me think about my failures and mistakes.	1.0333	.073	14.22	< .001	.8205
	4. My scars make me think about how weak I used to be	.7976	.087	9.125	< .001	.5944
2 Social Cognitions	10. My scars make me embarrassed in front of other people.	1.1282	.073	15.47	< .001	.8506
	23. I think that people judge me because of my scars.	1.0856	.081	13.34	< .001	.769
	16. I think that people stare at my scars.	.8331	.078	10.71	< .001	.6544
	18. My scars make me feel unattractive.	.9049	.072	12.56	< .001	.7359
	8. My scars make me feel shame.	.9427	.08	11.84	< .001	.7064
3 Positive Cognitions	1. My scar(s) represent how strong I am emotionally.	.7956	.064	12.51	< .001	.7577
	20. My scars make me feel hopeful about my future.	.564	.054	10.43	< .001	.6535
	2. My scar(s) represent how strong I am physically.	.4667	.059	7.955	< .001	.5317
	11. My scars make me feel tough, like I can get through anything.	.9671	.064	15.06	< .001	.8651
	5. My scars make me feel proud that I got through a very tough time	.9132	.078	11.67	< .001	.7094
4 Weak Cognitions	6. My scar(s) remind me that I am weak.	1.1533	.081	14.32	< .001	.8237
	7.My scars make me feel afraid;	.4434	.068	6.549	< .001	.4468
	12. My scars make me feel like I am weak	.9789	.07	14.02	< .001	.8085
5 Suicide Cognitions	26. My scars make me feel less afraid of dying.	.4863	.08	6.08	< .001	.4096
	22. My scars make me feel like I can’t change anything, like I’m stuck.	1.0915	.08	13.6	< .001	.7818
	17. My scars make me feel like I want to kill myself.	.5545	.055	10.02	< .001	.6236
	14. My scars make me feel hopeless.	.9206	.063	14.59	< .001	.8232
	25. I think that my scars make me unique.	-.016	.076	-.203	.839	-.0144
	19. My scars make me feel like I could kill myself if I wanted to.	.9394	.09	10.42	< .001	.6505

Analysis of the factor loadings revealed considerable variability across the different factors. The items of Factor 2 («Social Cognitions») demonstrated the strongest diagnostic utility, with standardized loadings ranging from .654 to .851. Factor 1 («Reminder Cognitions») and Factor 3 («Positive Cognitions») also showed adequate loadings for the majority of their items (.532-.820 and .532-.865, respectively).

However, several problematic aspects of the five-factor model were identified. Factor 4 («Weak Cognitions») included Item 7 with a low standardized loading (.447). Factor 5 («Suicide Cognitions») contained a statistically non-significant Item 25 (p = .839) with a minimal loading (-.014). Several items demonstrated loadings below the recommended threshold of .50 (Items 2, 7, 26). The considerable variability in loadings within the factors indicates heterogeneity of the measured constructs.

The unsatisfactory nature of the initial model is further supported by the values of key goodness-of-fit indices: χ²(220) = 817, p < .001; CFI = .781; TLI = .748; RMSEA = .107 (90% CI: .099-.115); SRMR = .100 (see Table 4). All these indices failed to meet the conventional thresholds indicative of a good model fit (CFI/TLI > .90; RMSEA < .08; SRMR < .08).

Table 4

Goodness-of-Fit Indices for the Five-Factor NSSI-SCS Model

χ² (Chi-square)		df  (Degrees of freedom)		p-value
817		220		< .001
				RMSEA 90% CI
CFI	TLI	SRMR	RMSEA	Lower Bound	Upper Bound
.781	.748	.1	.107	.0994	.115

Analysis of the internal reliability of the five-factor NSSI-SCS structure yielded satisfactory results for the factors "Weak Cognitions" (α = .702) and "Suicide-Related Cognitions" (α = .741), which met the minimum acceptable thresholds (see Table 5).

Table 5

Internal Reliability Indices for the Five-Factor NSSI-SCS Structure (Cronbach's Alpha, McDonald's Omega)

Factor	Cronbach's α	McDonald’s ω
1.Reminder Cognitions	.774	.775
2.Social Cognitions	.858	.861
3.Positive Cognitions	.838	.834
4.Weak Cognitions	.702	.737
5.Suicide Cognitions	.741	.764

The obtained results indicate that the original theoretical five-factor structure of the NSSI-SCS was not adequately replicated in the Russian-speaking sample, necessitating a revision of the scale's factor structure for this cultural context. Consequently, to investigate the questionnaire's factorial structure, an exploratory factor analysis (EFA) using principal component analysis (PCA) and oblimin rotation was conducted. The most suitable model was a three-factor solution, which was determined after the sequential removal of items with factor loadings below .5. Inspection of the scree plot confirmed the presence of three factors (Cattell’s criterion) (Figure 1).

Figure 1. Scree Plot of Components of the NSSI-SCS Scale

The internal consistency of the three-factor NSSI-SCS model was assessed using Cronbach’s alpha. The coefficients for all three factors exceeded .80, indicating good to excellent reliability (Table 6). Based on the scree plot analysis and these strong reliability indices, the first three components were retained for the final model.

Table 6 

Internal Consistency Indicators of the NSSI-SCS

Indicator	Cronbach's α	McDonald’s ω
Factor 1	.883	.889
Factor 2	.873	.875
Factor 3	.835	.84
Scale	.876	.882

A standard pattern matrix was used to interpret the three factors (Table 7). The first factor was interpreted as «Hopelessness», reflecting cognitions that NSSI scars lead to thoughts of weakness, hopelessness, and death. The second factor, designated as «Shame», encapsulated the belief that scars cause embarrassment and a fear of negative social evaluation. The third factor was labeled «Inner Strength», representing the perception of scars as demonstrations of emotional and physical resilience and a source of personal pride. A comparison with the original NSSI-SCS revealed notable structural differences. The «Hopelessness» factor comprised a combination of items: four from the original «Suicide Cognitions» subscale, two from «Weak Cognitions», and one from «Reminder Cognitions». The «Shame» factor primarily reproduced the original «Social Cognitions» subscale. The «Inner Strength» factor closely mirrored the original «Positive Cognitions» subscale, with the exception of a single cross-loading item (Item 25) from the «Suicide Cognitions» subscale.

Table 7

Factor Loadings of NSSI-SCS Statements

NSSI-SCS Statement	Factor Loading	Uniqueness
Factor 1 (Hopelessness)
19. My scars make me feel like I could kill myself if I wanted to.	.83	.396
22. My scars make me feel like I can’t change anything, like I’m stuck.	.8	.302
21. My scars make me feel like I can’t handle the future.	.793	.305
17. My scars make me feel like I want to kill myself.	.67	.511
6. My scar(s) remind me that I am weak.	.669	.45
15. My scars make me think about my failures and mistakes.	.638	.364
26. My scars make me feel less afraid of dying.	.62	.506
14. My scars make me feel hopeless.	.568	.336
9. My scars remind me of stressful things that happened to me in the past.	.509	.607
Factor 2 (Shame)
10. My scars make me embarrassed in front of other people.	.861	.258
23. I think that people judge me because of my scars.	.762	.352
24. I think that I would have better relationships if I didn’t have any scars.	.757	.422
8. My scars make me feel shame.	.755	.43
16. I think that people stare at my scars.	.723	.447
18. My scars make me feel unattractive.	.711	.352
Factor 3 (Inner Strength)
11. My scars make me feel tough, like I can get through anything.	.842	.29
1. My scar(s) represent how strong I am emotionally.	.796	.353
5. My scars make me feel proud that I got through a very tough time.	.793	.371
20. My scars make me feel hopeful about my future.	.684	.538
25. I think that my scars make me unique.	.657	.559
2. My scar(s) represent how strong I am physically.	.645	.581

The following items from the original scale were excluded from the final three-factor model due to insufficient factor loadings (all below the .5 threshold) and are presented in Table 8.

Table 8

Factor Loadings of Items Excluded from the Three-Factor NSSI-SCS Model

Factor Loadings
NSSI-SCS Statement	Factor			Uniqueness
	1	2	3
3. My scars bring back memories of things that I don’t want to remember	.13	.49	.204	.648
4. My scars make me think about how weak I used to be	.17	.38	.152	.742
7. My scars make me feel afraid	.332	.327	.09	.663
12. My scars make me feel like I am weak	.469	.312	-.23	.468
13. I think about my scars.	.444	.265	.12	.597

The three extracted factors collectively account for 58.4% of the total variance, which is considered satisfactory for clinical psychology and psychometric questionnaires (see Table 9). This figure exceeds the minimum threshold of 50% for valid psychological scales, indicating that the three-factor model adequately captures the primary patterns of inter-item relationships within the instrument.

Table 9 

Variance Explained by the Three-Factor NSSI-SCS Structure

Factor	Sum of Squared Loadings  (SS)	% of Variance	Cumulative %
1	4.57	21.8	21.8
2	4.06	19.3	41.1
3	3.64	17.3	58.4

A comparison of the original five-factor model (see Table 4) and the three-factor model (see Table 10) using goodness-of-fit indices revealed that the three-factor model is statistically more justified for the obtained empirical data from the Russian-speaking sample. 

Table 10

Goodness-of-Fit Indices for the Three-Factor NSSI-SCS Model

χ² (Chi-square)			df (Degrees of freedom)			p-value
636			186			< .001
					RMSEA 90%  CI
CFI	TLI	SRMR		RMSEA	Lower Bound		Upper Bound
.826	.803	.0855		.101	.0927		.11

The three-factor model demonstrates a better normed chi-square (χ²/df) ratio (636/186 = 3.42) compared to the five-factor model (817/220 = 3.71). Although both values exceed the acceptable threshold of 2, the difference indicates a superior fit for the three-factor solution. Furthermore, the CFI for the three-factor model (.826) is substantially higher than that of the five-factor model (.781) and approaches the acceptability threshold (≥ .90). The TLI for the three-factor model (.803) meets the marginal "tolerance" threshold of .80, unlike the five-factor model (TLI = .748). A key improvement is observed in the RMSEA value: .107 for the five-factor model indicates a poor fit, while .086 for the three-factor model is considered acceptable. However, the SRMR values for both models (.100 for the five-factor and .101 for the three-factor) exceed the strict threshold of .08, suggesting residual discrepancies remain in both configurations. Overall, on all key indices except the SRMR, the three-factor model demonstrates a statistically more adequate fit to the data. 

A direct comparison using the Chi-Square Difference Test yielded a statistically significant result (Δχ² = 181, Δdf = 34, p < .001). This finding confirms that the three-factor model provides a statistically superior fit to the five-factor model, as it achieved a significant improvement in model fit while utilizing fewer parameters. 

Correlation analysis (Spearman’s ρ) revealed a substantial positive intercorrelation between the «Hopelessness» (F1) and «Shame» (F2) subscales (ρ = .577, p < .001). In contrast, the "Inner Strength" (F3) subscale demonstrated no significant correlation with either F1 or F2. This supports its conceptual independence, as it appears to tap into a distinct construct related to perceptions of resilience and personal strength derived from scars. Conversely, the «Hopelessness» and «Shame» subscales collectively reflect the negative aspects of cognitive and emotional scar appraisal (Figure 2). 

Figure 2. Intercorrelations between the Factors of the NSSI-SCS

Data on the Convergent and Discriminant Validity of the Non-Suicidal Self-Injury Scar Cognition Scale (NSSI-SCS)

Analysis of bivariate correlations (Spearman's ρ) revealed a pattern of statistically significant relationships between the NSSI-SCS factors and the ISAS scales (see Table 5). It is important to note that while statistically significant due to the sample size, several of the observed correlation coefficients were modest in magnitude (ρ < .2). Nevertheless, their specific pattern contributes to the understanding of the scale's construct validity. Furthermore, the «Hopelessness» subscale score was significantly correlated with a broad range of self-injury functions (ISAS), including Affect Regulation, Self-Punishment, Anti-Dissociation, Anti-Suicide, Interpersonal Boundaries, Self-Care, Sensation Seeking, Toughness, Autonomy, and Marking Distress. The «Shame» subscale showed a more specific pattern of correlations, being significantly associated with Self-Punishment, Anti-Suicide, Interpersonal Boundaries, and Revenge (Table 11). The «Inner Strength» score showed significant, though weak, positive correlations with a broad range of self-injury functions, including affect regulation, anti-dissociation, interpersonal boundaries, self-care, sensation seeking, toughness, autonomy, and marking distress (ρ values ranging from .136 to .362).

Table 11

Correlations (Spearman’s ρ) of NSSI-SCS factors with the Inventory of Statements about Self-Injury (ISAS)

Functions of Self-Injury (ISAS)	Factor 1 "Hopelessness"	Factor 2 "Shame"	Factor 3 “Inner Strength”
Affect regulation	.214***	.087	.185**
Self-punishment	.432***	.284***	.069
Anti-dissociation	.185**	-.01	.157*
Anti-suicide	.347***	.19**	.174**
Interpersonal boundaries	.239***	.184**	.237***
Self-care	.287***	.091	.271***
Sensation-seeking	.144*	.081	.351***
Peer-bonding	.071	.05	.136*
Interpersonal influence	.122	.079	.28***
Toughness	.217***	.081	.283***
Revenge	.118	.16*	.172**
Autonomy	.158*	.056	.222***
Marking distress	.289***	.105	.362***

Note.*p < .05, **p < .01, *** p < .001.

Analysis of discriminant validity established that the «Hopelessness» and «Shame» subscales of the NSSI-SCS demonstrated significant positive correlations (Spearman’s ρ) with total scores on measures of social anxiety (Liebowitz Social Anxiety Scale, LSAS), rumination (Ruminative Responses Scale, RRS), body-image dysphoria (Situational Inventory of Body-Image Dysphoria, SIBID), and suicide ideation (Beck Scale for Suicide Ideation). In contrast, the "Inner Strength" subscale showed no significant associations with these clinical constructs (Table 12).

Table 12

Bivariate Correlations (Spearman’s ρ) Between the Factors of the NSSI-SCS and Total Scores on the LSAS (Liebowitz Social Anxiety Scale), RRS (Ruminative Responses Scale), SIBID (Situational Inventory of Body-Image Dysphoria), and the Beck Scale for Suicide Ideation

	"Hopelessness"	"Shame"	“Inner Strength”
Suicidal risk	.43***	.15*	-.084
Social anxiety	.396***	.365***	.035
Body dissatisfaction	.495***	.401***	.035
Rumination	.427***	.383***	.056

Note.*p < .05, *** p < .001.

To identify differences in NSSI-SCS scores between patients with scars in different locations (visible vs. hidden), a non-parametric Mann-Whitney U test was conducted (Table 13). The analysis revealed a statistically significant difference between the groups on the «Inner Strength» subscale (U = 2917, p < .001). Respondents with visible scars (M = 10.2, SD = 4.79) reported significantly higher scores on this subscale compared to those with concealed scars (M = 8.29, SD = 3.79). This result indicates that individuals with scars apparent to others are more likely to perceive them as symbols of resilience, emotional strength, and overcoming adversity. In contrast, no statistically significant differences were found between the groups on the «Hopelessness» (U = 3887, p = .344) and «Shame» (U = 3913, p = .380) subscales. This suggests that the negative cognitive appraisals of scars – such as feelings of hopelessness, suicidality, and social shame – are prevalent regardless of their visibility.

Table 13

Differences in NSSI-SCS scores between patients with scars in different locations (visible vs. hidden) Mann-Whitney U-test 

	Visible scars (n = 121)		Hidden scars (n = 70)		Assessment of the validity of differences
	M	SD	M	SD	Mann-Whitney U-test	p	Cohen’s d
Inner Strength	10.2	4.79	8.29	3.79	2917	<.001	.311
Hopelessness	18	8.61	18.29	7.06	3887	.344	.082
Shame	11.9	5.91	12.27	5.23	3913	.38	.076

A comparative analysis was conducted between respondents scoring in the highest (Q4) and lowest (Q1) quartiles on each of the NSSI-SCS subscales using the Mann-Whitney U test. Inner Strength Subscale. The proportion of respondents in the high-scoring group (Q4) was 33.5% (n=79). When compared to the low-scoring group (Q1, n=80), the high-scoring group demonstrated significantly greater endorsement of the following NSSI functions: Affect Regulation (p = .004), Anti-Dissociation (p = .036), Anti-Suicidal (p = .009), Interpersonal Boundaries (p < .001), Self-Care (p < .001), Sensation-Seeking (p < .001), Interpersonal Influence (p < .001), Toughness (p < .001), Revenge (p = .006), Autonomy (p = .004), and Marking Distress (p < .001)Hopelessness Subscale. High scores on this subscale were observed in 31.8% of participants (Q4, n=75). This group, compared to the low-scoring group (Q1, n=49), exhibited significantly elevated scores on established clinical measures: the Beck Scale for Suicide Ideation (p < .001), the Liebowitz Social Anxiety Scale (p < .001), the Situational Inventory of Body-Image Dysphoria (p < .001), and the Ruminative Responses Scale (p < .001). Furthermore, they reported higher scores on several NSSI functions, including Affect Regulation (p < .005), Anti-Dissociation (p = .004), Anti-Suicidal (p < .001), Interpersonal Boundaries (p < .003), Self-Care (p < .001), Sensation-Seeking (p = .012), Toughness (p < .001), Autonomy (p = .028), and Marking Distress (p < .001). Shame Subscale. The high-scoring group (Q4) for this subscale comprised 35.6% of respondents (n=84). Comparative analysis with the low-scoring group (Q1, n=41) revealed that the Q4 group had significantly higher scores on measures of social anxiety (p < .001), body-image dysphoria (p < .001), and rumination (p < .001). They also endorsed significantly higher scores on specific NSSI functions: Self-Punishment (p < .001), Anti-Suicidal (p = .048), Interpersonal Boundaries (p = .007), Sensation-Seeking (p = .045), and Marking Distress (p = .015).

Discussion 

The Russian-language adaptation of the Non-Suicidal Self-Injury Scar Cognition Scale (NSSI-SCS) resulted in a psychometrically robust 21-item instrument, structured around a three-factor model that demonstrated superior fit and validity compared to the original five-factor structure. All three subscales exhibited high internal consistency (Cronbach's α > .80). This adaptation process involved the removal of five items from the original 26-item English version due to insufficient factor loadings (< .5) in the exploratory analysis. The final model consolidates the original four negative cognition subscales – "Reminder Cognitions," "Social Cognitions," "Weak Cognitions," and "Suicide Cognitions" – into two broader, clinically salient factors: 1. Hopelessness, which integrates cognitions related to suicidal ideation, personal weakness, and distressing reminders of past experiences. 2. Shame, which captures experiences of social stigmatization and embarrassment.

The original "Positive Cognitions" subscale was retained and conceptually refined as "Inner Strength," reflecting the perception of scars as a symbol of personal resilience and endurance. This three-factor structure is consistent with established theoretical models of scar perception following NSSI (e.g., Bachtelle & Pepper, 2015; Lewis & Mehrabkhani, 2016).

In this way this study operationalizes a set of latent constructs reflecting the cognitive appraisal of scars following NSSI. The construct 'Inner Strength' is theoretically defined as the perception of scars as symbols of resilience, overcoming adversity, and emotional endurance. The construct 'Shame' is defined as a cognitive-affective response encompassing the anticipation of social judgment and feelings of body rejection. The construct 'Hopelessness' amalgamates cognitions linking scars to feelings of doom, suicidal ideation, and an inability to change.

The study found that the "Inner Strength" indicator is a specific construct associated with the functionality of non-suicidal self-injurious behavior. Similar findings were reported in the study by T. Burke (Burke et al., 2017). Its lack of association with measures of psychological distress (LSAS, RRS, SIBID, BSSI) suggest its relative independence. A person may experience high social anxiety or rumination without associating these states with their scars The identified pattern of weak-to-moderate correlations between the «Inner Strength» factor and the functions of self-injury suggests its potential role in reflective aspects of coping with the consequences of non-suicidal self-injury. The «Inner Strength» factor appears to tap into a parallel cognitive process where scars are appraised through a lens of resilience and survival. It is important to acknowledge that the correlations with ISAS functions, while statistically significant, were generally modest (see Table 5). This indicates that viewing scars as a symbol of inner strength is a distinct, though not predominant, cognitive pathway that can coexist with both adaptive and maladaptive coping mechanisms which aligns with findings from other studies (Kendall et al., 2021; Linington, 2024). 

The «Inner Strength» factor identified in our study finds a compelling parallel in contemporary clinical research (Sripunya et al., 2024) identified «inner strengths» – conceptualized as resilience and self-compassion – as a key mediator attenuating the relationship between emotional distress and self-injurious behaviors. While their construct is measured more broadly, the resonance with our findings suggests that perceiving scars as symbols of resilience may tap into a similar protective psychological resource, rather than being merely a cognitive reappraisal. Therefore, our findings, consistent with the broader literature on psychology (e.g., Zhao et al., 2023), suggest that therapeutic approaches could benefit from investigating a shift in focus from exclusively mitigating negative symptoms toward the deliberate cultivation of positive psychological resources. 

Non-suicidal self-injury has pronounced negative long-term consequences, leading to a vicious cycle of distress (Burke et al., 2017). The relationship between the indicator of Negative appraisal of scars (including the indicators "Hopelessness" and "Shame", affecting about one-third of the sample) and worsening of psychopathological symptoms: increased suicidal ideation, greater social anxiety, body dissatisfaction, and rumination, which is consistent with previous research (Burke et al., 2020; Glenn, 2024). 

However, the modest magnitude of several correlations (e.g., ρ ≈ .2) suggests that, while statistically significant and theoretically meaningful, the shared variance between these constructs is limited. This indicates that the NSSI-SCS factors capture unique aspects of scar-related cognition not fully explained by general measures of suicidality, anxiety, rumination, or body image.

Our analysis of scar visibility using the Mann-Whitney U test revealed a clinically significant dissociation in cognitive appraisals. While no differences emerged on the "Hopelessness" (U = 3887, p = .344) and "Shame" (U = 3913, p = .380) subscales – suggesting the pervasive nature of negative scar-related cognitions regardless of visibility – individuals with visible scars reported significantly higher "Inner Strength" scores (U = 2917, p < .001). This pattern aligns with previous qualitative research (Chandler, 2014; Lewis & Mehrabkhani, 2016). The persistent shame and hopelessness across both groups corroborates findings by Burke et al. (2020) that concealment strategies may not mitigate underlying psychological distress. However, the enhanced "Inner Strength" appraisals in the visible scars group suggest that public visibility might, for some individuals, facilitate a narrative transformation process wherein scars become integrated into identity as markers of resilience rather than merely concealed sources of shame.

The results of the Russian adaptation, which differ from the English version, largely reflect cultural differences between Western and Eastern methodologies (Myung et al., 2024). In Western cultures (especially individualistic societies like the United States), more attention is paid to individual experiences. In Russian-speaking culture, which is more aligned with collectivist models, "stigma and shame" play a greater role.  Whereas Western models of NSSI often frame the behavior through the lens of emotional regulation, Eastern cultures place more emphasis on the social context, embarrassment, and stigma. This is consistent with the emergence of «shame» as a separate factor in the Russian version. This cultural specificity is supported by empirical evidence from other studies, for instance, research by Thompson & Bhugra (2000). Another study (Gholamrezaei et al., 2017) authors highlight the heightened salience of interpersonal functions of NSSI in collectivist contexts, as well as the substantial role of culturally-bound stress.

Furthermore, research by Chen et al. (2021) demonstrates the considerable influence of the social context and collectivistic values on the pronounced experience of shame and guilt associated with self-injurious behaviors.

The three-factor structure of the Russian-language version of the NSSI-SCS obtained in our study finds empirical parallels in cross-cultural validation studies of other clinical instruments. Specifically, the validation of the Serbian version of the Clinical Assessment Interview for Negative Symptoms (CAINS) revealed a three-factor structure differing from the original two-factor model (Ristić et al., 2020). Across various cultural contexts have repeatedly demonstrated differences in factor structure of different clinical instruments from the original model, without precluding the valid use of the adapted versions.  Further supporting the methodological approach of identifying a culturally specific factor structure, our findings align with adaptation studies of other well-established psychological instruments in Russia. The large-scale validation of Budner's Tolerance-Intolerance of Ambiguity Scale (Kornilova & Chumakova, 2014) confirmed a stable two-factor model distinguishing Tolerance for Uncertainty (TU) and Intolerance for Uncertainty (IU) as separate constructs, rather than a unidimensional one.

Limitations and prospects

Among the limitations of the study, it is important to note the characteristics of the surveyed groups – most of the sample (78%) consisted of women. The gender imbalance in the sample, characterized by a predominance of women (74.4%), reflects established epidemiological patterns of NSSI prevalence, which consistently show a higher prevalence of this behavior in the female population. However, we acknowledge that the underrepresentation of men limits the ability to extrapolate the findings to the male population and consider this an important direction for future research.

Another limitation is the lack of an assessment of test-retest reliability. Furthermore, the interpretation of some correlational findings, particularly for the «Inner Strength» subscale, should be tempered by the recognition that several statistically significant correlations were weak in magnitude (ρ < .2), their practical and clinical significance may be limited. Further clarification is needed regarding the concept of «Inner Strength» as a specific attitude toward one's own scars. While this indicator reflects a perspective contrary to the negative appraisal of scars, it does not show inverse correlations with measures of general psychological distress.

The prospect for further research is the practical application of the adapted version. Studies based on this can be used to develop recommendations for the prevention of NSSI relapses and to make decisions about cosmetic surgery and body modifications. 

Conclusions

This study on the validation of the Russian-language version of the Nonsuicidal Self-Injury Scar Cognition Scale (NSSI-SCS) highlights the key role of subjective scar perception in the psychological well-being of individuals with a history of self-injurious behavior. 

The findings of the present study provide comprehensive support for the construct validity of the Russian-language NSSI-SCS. Unlike the original five-factor model, validation with a Russian-speaking sample revealed a conceptually grounded three-factor structure: 1) «Hopelessness» – integrates internal distress (suicidal ideation, feelings of weakness), reflecting global negative self-perception.  2) «Shame" – focuses on social distress (stigmatization, embarrassment), which holds particular conceptual significance in cultures with collectivistic characteristics. 3) «Inner Strength» – represents an independent positive construct symbolizing resilience and overcoming adversity.

Structural validity, established via EFA and CFA, confirmed a three-factor model consistent with theoretical conceptions of the cognitive appraisal of scars. Convergent validity were largely supported by predictable moderate-to-strong associations of the 'Hopelessness' and 'Shame' scales with relevant measures. Discriminant validity of the 'Inner Strength' scale was also supported, underscoring its uniqueness as a construct distinct from general negative affect. Finally, confirmed validity based on the differences between groups with visible and invisible scar locations adds robust evidence in favor of the measure's validity.

The three-factor model represents a culturally adapted and conceptually valid framework that more accurately captures the key dimensions of scar perception within Russian-speaking populations. This model provides a more parsimonious yet profound understanding of the cognitive landscape associated with the consequences of non-suicidal self-injury in this specific cultural context.

Ethics Statement

The study was approved by The Local Ethics Committee of Ryazan State Medical University (protocol of the LEC №3 meeting). Informed consent was obtained from all study participants. The research was conducted anonymously.

Author Contributions

Aleхandrina A. Grigoreva conceived of the idea, developed the theory, write main text. Anastasia K. Kondratovich performed the computations, verified the statistical methods, Ilya A. Fedotov supervised the findings of this work, made edits to the text, Maksim P. Marachev - correction of the methodology section, made stylistic edits to the text, Farah M. Trabelsi and Arina N. Mokritskaya – primary data was collected. All authors discussed the results and contributed to the final manuscript.

Conflict of Interest

The authors declare no conflict of interest.

Acknowledgements

This study received no external funding.

References

Aksel'rov, M.A., Bokhan, N.A., Bukhna, A.G., Vasil'eva, D.M., Garagasheva, E.P., Golenkov, A.V., Evseev, V.D., Enikolopov, S.N., Zhilova, Y.N., Zavalova, E.R., Zotov, P.B., Igumnov, S.A., Lodygin, A.N., Lyubov, E.B., Mandel', A.I., Merinov, A.V., Peshkovskaya, A.G., Prokopovich, G.A., Rakhimkulova, A.S., ... & Chistopolskaya, K.A. (2021). Suitsidal'nye i nesuitsidal'nye samopovrezhdeniia podrostkov [Suicidal and nonsuicidal self-injurious behaviors in adolescents]. Vektor buk.

Bachtelle, S.E., & Pepper, C.M. (2015). The physical results of nonsuicidal self-injury: The meaning behind the scars. The Journal of Nervous and Mental Disease, 203(12), 927–933. https://doi.org/10.1097/NMD.0000000000000398

Baranskaia, L.T., Tkachenko, A.E., & Tataurova, S.S. (2008). Adaptatsiia metodiki issledovaniia obraza tela v klinicheskoi psikhologii [Adaptation of the body image research methodology in clinical psychology]. Obrazovanie i Nauka [Education and Science], (3), 63–69. https://elar.rsvpu.ru/handle/123456789/33050

Beck, A.T., Kovacs, M., & Weissman, A. (1979). Assessment of suicidal intention: the Scale for Suicide Ideation. Journal of consulting and clinical psychology, 47(2), 343. https://doi.org/10.1037/0022-006X.47.2.343

Buelens, T., Luyckx, K., Gandhi, A., Kiekens, G., & Claes, L. (2019). Non-suicidal self-injury in adolescence: Longitudinal associations with psychological distress and rumination. Journal of abnormal child psychology, 47(9), 1569–1581. https://doi.org/10.1007/s10802-019-00531-8

Burke, T.A., Ammerman, B.A., Hamilton, J.L., Stange, J.P., & Piccirillo, M. (2020). Nonsuicidal self-injury scar concealment from the self and others. Journal of psychiatric research, 130, 313-320. https://doi.org/10.1016/j.jpsychires.2020.07.040

Burke, T.A., Hamilton, J.L., Abramson, L.Y., & Alloy, L.B. (2015). Non-suicidal self-injury prospectively predicts interpersonal stressful life events and depressive symptoms among adolescent girls. Psychiatry Research, 228(3), 416–424. https://doi.org/10.1016/j.psychres.2015.06.021

Burke, T.A., Hamilton, J.L., Cohen, J.N., Stange, J.P., & Alloy, L.B. (2016). Identifying a physical indicator of suicide risk: Non-suicidal self-injury scars predict suicidal ideation and suicide attempts. Comprehensive psychiatry, 65, 79–87. https://doi.org/10.1016/j.comppsych.2015.10.008

Burke, T.A., Olino, T.M., & Alloy, L.B. (2017). Initial psychometric validation of the non-suicidal self-injury scar cognition scale. Journal of psychopathology and behavioral assessment, 39, 546-562. https://doi.org/10.1007/s10862-017-9595-9

Chandler, A. (2014). Narrating the self-injured body. Medical Humanities, 40(2), 111-116. https:/doi.org/10.1136/medhum-2013-010488

Chen, X., Zhou, Y., Li, L., Hou, Y., Liu, D., Yang, X., & Zhang, X. (2021). Influential factors of non-suicidal self-injury in an eastern cultural context: a qualitative study from the perspective of school mental health professionals. Frontiers in psychiatry, 12, 681985. https://doi.org/10.3389/fpsyt.2021.681985

Dar'in, E.V., & Zaitseva, O.G. (2023). Epidemiologiia nesuitsidal'nogo samopovrezhdaiushchego povedeniia (nesistematicheskii povestvovatel'nyi obzor) [Epidemiology of non-suicidal self-injurious behavior (non-systematic narrative review)]. Obozrenie Psikhiatrii i Meditsinskoi Psikhologii imeni V.M. Bekhtereva [Review of Psychiatry and Medical Psychology named after V.M. Bekhterev], 57(2), 8–19. https://doi.org/10.31363/2313-7053-2023-694

Dåstøl, A., Stänicke, L.I., & Mossige, S. (2023). “Treat me like a fellow human”: how young adults who blog about self-harm describe positive encounters with health care workers. Nordic Psychology, 75(2), 97–112. https://doi.org/10.1080/19012276.2022.2063929

Duarte, T.A., Paulino, S., Almeida, C., Gomes, H.S., Santos, N., & Gouveia-Pereira, M. (2020). Self-harm as a predisposition for suicide attempts: A study of adolescents' deliberate self-harm, suicidal ideation, and suicide attempts. Psychiatry research, 287, 112553. https://doi.org/10.1016/j.psychres.2019.112553

Dyer, A., Hennrich, L., Borgmann, E., White, A.J., & Alpers, G.W. (2013). Body image and noticeable self-inflicted scars. The Journal of nervous and mental disease, 201(12), 1080–1084. https://doi.org/10.1097/NMD.0000000000000057

Edriss, M., Monconduit, R., St Claire, K., Akers, K.G., & Mehregan, D. (2022). Treatment of self-harm scars: A scoping review. Dermatologic surgery, 48(8), 809–814. https://doi.org/10.1097/dss.0000000000003499

Foley, M. (2022). The Story behind Their Scars: A Phenomenological Study of Self-Harm through the Eyes of Clinicians [Doctoral dissertation, The Chicago School of Professional Psychology].

Fox, C., & Flower, R. (2021). Exploring student perceptions of self-harming behaviour: a qualitative study. British Journal of Guidance & Counselling, 49(3), 445–455. https://doi.org/10.1080/03069885.2020.1755951

Gardner, K.J., Klonsky, E.D., & Selby, E.A. (2021). Advancing theory of suicide and non-suicidal self-injury. Frontiers in psychology, 12, 780029. https://doi.org/10.3389/fpsyg.2021.780029

Gholamrezaei, M., De Stefano, J., & Heath, N.L. (2017). Nonsuicidal self‐injury across cultures and ethnic and racial minorities: A review. International journal of psychology, 52(4), 316–326. https://doi.org/10.1002/ijop.12230

Glenn, L.E. (2024). A brief cognitive behavioral treatment for nonsuicidal self-injury scars [Doctoral dissertation, University of Wyoming]. ProQuest Dissertations & Theses Global.

Grigor'eva, I.V.& Enikolopov, S.N. (2016). Aprobatsiia oprosnikov Shkala sotsial'noi trevozhnosti liubovnitsa i Shkala strakha negativnoi otsenki (kratkaia versiia) [Validation of the Liebowitz Social Anxiety Scale and the Brief Fear of Negative Evaluation Scale]. Natsional'nyi Psikhologicheskii Zhurnal [National Psychological Journal], (1), 31–44. https://doi.org/10.11621/npj.2016.0105

Gutridge, K., Dunlop, B.J., Patterson, M., Mitchell, H., Philbin, J., Walker, T., Ranote, S., Robinson, L., & Abel, K.M. (2019). An exploratory study of women prisoners' attitudes towards their self-harm and the use of medical skin camouflage. The Journal of Forensic Psychiatry & Psychology, 30(1), 167–184. https://doi.org/10.1080/14789949.2018.1530285

Ho, W., Jones, C.D., & Anderson, W. (2018). Deliberate self-harm scars: Review of the current literature. JPRAS open, 16, 109–116. https://doi.org/10.1016/j.jpra.2018.03.001

Hodgson, S. (2004). Cutting through the silence: a sociological construction of self‐injury. Sociological inquiry, 74(2), 162–179. https://doi.org/10.1111/j.1475-682X.2004.00085.x

Kendall, N., MacDonald, C., & Binnie, J. (2021). Blogs, identity, stigma and scars: The legacy of self-injury. Mental Health Review Journal, 26(3), 258–278. https://doi.org/10.1108/MHRJ-06-2020-0041

Kibitov, A.A., Potanin, S.S., Iagina, O.M., Borodin, V.I., & Morozova, M.A. (2025). Psychometric properties and factor structure analysis of the inventory of statements about self-injury (ISAS) in a Russian non-clinical sample. Consortium Psychiatricum, 6(1), 18–29. https://doi.org/10.17816/CP15537

Kiekens, G., Hasking, P., Bruffaerts, R., Alonso, J., Auerbach, R.P., Bantjes, J., Benjet, C., Boyes, M., Chiu, W.T., Claes, L., Cuijpers, P., Ebert, D.D., Mak, A., Mortier, P., O'Neill, S., Sampson, N.A., Stein, D.J., Vilagut, G., Nock, M.K., & Kessler, R.C. (2023). Non-suicidal self-injury among first-year college students and its association with mental disorders: results from the World Mental Health International College Student (WMH-ICS) initiative. Psychological medicine, 53(3), 875–886. https://doi.org/10.1017/S0033291721002245

Klemera, E., Brooks, F.M., Chester, K.L., Magnusson, J., & Spencer, N. (2017). Self-harm in adolescence: protective health assets in the family, school and community. International journal of public health, 62, 631–638. https://doi.org/10.1007/s00038-016-0900-2

Klonsky, E.D., Victor, S.E., & Saffer, B.Y. (2014). Nonsuicidal self-injury: What we know, and what we need to know. The Canadian Journal of Psychiatry, 59(11), 565–568. https://doi.org/10.1177/070674371405901101

Kornilova, T.V., & Chumakova, M.A. (2014). Shkaly tolerantnosti i intolerantnosti k neopredelennosti v modifikatsii oprosnika S. Bandera [Scale of Tolerance and Intolerance to Uncertainty in the Modified S. Bandera Questionnaire]. Eksperimental'naia psikhologiia [Experimental Psychology], 7(1), 92–110. https://psyjournals.ru/journals/exppsy/archive/2014_n1/68181

Kristen, A., Lecchi, T., Loades, M.E., & Midgley, N. (2024). “I can’t escape my scars, even if I do get better”: A qualitative exploration of how adolescents talk about their self-harm and self-harm scars during cognitive behavioural therapy for depression. Clinical child psychology and psychiatry, 29(4), 1277–1295. https://doi.org/10.1177/13591045241241348

Kuznetsova, S.O. Abramova, A.A., Efremov, A.G., & Enikolopov, S.N. (2021). Samopovrezhdaiushchee povedenie: aprobatsiia oprosnika na opredelenie urovnia povedeniia s prednamerennym samopovrezhdeniem (The Deliberate Self-Harm Inventory) [Self-harming behavior: approbation of a questionnaire for determining the level of deliberate self-harm behavior (The Deliberate Self-Harm Inventory)]. Meditsinskaia psikhologiia v Rossii: setevoi nauchnyi zhurnal [Medical Psychology in Russia: online scientific journal], 13(5).

Lewis, S.P., & Mehrabkhani, S. (2016). Every scar tells a story: Insight into people’s self-injury scar experiences. Counselling Psychology Quarterly, 29(3), 296–310. https://doi.org/10.1080/09515070.2015.1088431

Linington, C. (2024). Impacts of Self-Harm Scars on Psychosocial Functioning, Quality of Life, and Recovery in People With Histories of Self-Harm: A Scoping Review. Psychotherapy and Counselling Journal of Australia, 12(2). https://doi.org/10.59158/ 001c.125796

Lloyd, B., Blazely, A., & Phillips, L. (2018). Stigma towards individuals who self harm: Impact of gender and disclosure. Journal of Public Mental Health, 17(4), 184–194. https://doi.org/10.1108/JPMH-02-2018-0016

Mahtani, M. (2018). Stamping out Stigma-The Current State of Mental Health Awareness in Hong Kong and Well-Being in the Workplace. 

Nock, M.K., & Prinstein, M.J. (2005). Contextual features and behavioral functions of self-mutilation among adolescents. Journal of abnormal psychology, 114(1), 140. https://doi.org/10.1037/0021-843X.114.1.140

Nock, M.K., Joiner Jr, T.E., Gordon, K.H., Lloyd-Richardson, E., & Prinstein, M.J. (2006). Non-suicidal self-injury among adolescents: Diagnostic correlates and relation to suicide attempts. Psychiatry research, 144(1), 65–72. https://doi.org/10.1016/j.psychres.2006.05.010

Nunnally, J.C. (1978). An Overview of Psychological Measurement. In: Wolman, B.B. (eds) Clinical Diagnosis of Mental Disorders. Springer, Boston, MA. https://doi.org/10.1007/978-1-4684-2490-4_4

Pol'skaia N.A. (2014). Prichiny samopovrezhdaiushchego povedeniia molodezhi (na osnove shkaly samootcheta) [The reasons of self-injurious behavior in youth (based on a self-report scale)]. Konsul'tativnaia Psikhologiia i Psikhoterapiia [Counseling Psychology and Psychotherapy], (2), 140–152. https://psyjournals.ru/journals/cpp/archive/2014_n2/72333

Pol'skaia N.A. (2017). Fenomenologiia i funktsii samopovrezhdaiushchego povedeniia pri normativnom i narushennom psikhicheskom razvitii [The phenomenology and functions of self-harming behavior in normative and impaired mental development] [Doctoral dissertation, St. Petersburg State University]. 

Pugovkina, O.D., Syrokvashina, A.D., Istomin, M., & Kholmogorova, A.B. (2021). Ruminativnoe myshlenie kak kognitivnyi faktor khronifikatsii depressii: opredelenie poniatiia i validnostʹ instrumentariia [Ruminative thinking in chronic depression: Concept and validity of measures]. Konsulʹtativnaia psikhologiia i psikhoterapiia [Counseling Psychology and Psychotherapy], 29(3), 88–115. https://doi.org/10.17759/cpp.2021290307

Ribeiro, J.D., Franklin, J.C., Fox, K.R., Bentley, K.H., Kleiman, E.M., Chang, B.P., & Nock, M.K. (2016). Self-injurious thoughts and behaviors as risk factors for future suicide ideation, attempts, and death: a meta-analysis of longitudinal studies. Psychological medicine, 46(2), 225–236. https://doi.org/10.1017/S0033291715001804

Richmond, S., Hasking, P., & Meaney, R. (2017). Psychological distress and non-suicidal self-injury: The mediating roles of rumination, cognitive reappraisal, and expressive suppression. Archives of Suicide Research, 21(1), 62–72. https://doi.org/10.1080/13811118.2015.1008160

Ristić, I., Jerotić, S., Zebić, M., Savić, B., Vuković, V., Russo, M., Voskresenski, T., & Marić, N.P. (2020). Factorial structure of the Serbian version of the Clinical Assessment Interview for Negative Symptoms–evidence for three factors of negative symptoms. Frontiers in Psychology, 11, 570356. https://doi.org/10.3389/fpsyg.2020.570356

Rodriguez-Blanco, L., Carballo, J.J., & Baca-Garcia, E. (2018). Use of ecological momentary assessment (EMA) in non-suicidal self-injury (NSSI): A systematic review. Psychiatry research, 263, 212-219. https://doi.org/10.1016/j.psychres.2018.02.051

Sripunya,  P., Wongpakaran,  T., & Wongpakaran,  N. (2024). The Relationship Between Feeling of Emptiness and Non-Suicidal Self-Injury in Borderline Personality Disorder Symptoms: The Mediating Role of the Inner Strengths. Preprints. https://doi.org/10.20944/preprints202409.1755.v1

Takaya, K., Hayashi, R., Aramaki-Hattori, N., Okabe, K., Sakai, S., Asou, T., & Kishi, K. (2020). Treatment of deliberate self-harm scars with rotated thin-skin graft and minced-skin graft. Plastic and Reconstructive Surgery–Global Open, 8(8), e3020. https://doi.org/10.1097/gox.0000000000003020

Thompson, N., & Bhugra, D. (2000). Rates of deliberate self-harm in Asians: Findings and models. International Review of Psychiatry, 12(1), 37-43. https://doi.org/10.1080/09540260074102

Van Orden, K.A., Witte, T.K., Gordon, K.H., Bender, T.W., & Joiner Jr, T.E. (2008). Suicidal desire and the capability for suicide: tests of the interpersonal-psychological theory of suicidal behavior among adults. Journal of consulting and clinical psychology, 76(1), 72. https://doi.org/10.1037/0022-006X.76.1.72 

Weaver, T.L., Resnick, H.S., Kokoska, M.S., & Etzel, J.C. (2007). Appearance-related residual injury, posttraumatic stress, and body image: Associations within a sample of female victims of intimate partner violence. Journal of traumatic stress, 20(6), 999–1008. https://doi.org/10.1002/jts.20274

Whitlock, J., Exner-Cortens, D., & Purington, A. (2014). Assessment of nonsuicidal self-injury: Development and initial validation of the Non-Suicidal Self-Injury–Assessment Tool (NSSI-AT). Psychological assessment, 26(3), 935. https://doi.org/10.1037/a0036611

Zhao, H., Zhou, A., Chi, H., Zhao, J., Xia, R., & Pan, C. (2023). Cumulative Risks and Non-Suicidal Self-Injury in Adolescents: Protective Effect of Personality Strengths. Authorea Preprints. https://doi.org/10.22541/au.167948822.27705688/v1

Zinchuk, M., Kustov, G., Popova, S., Mishin, I., Voinova, N., Gersamija, A., Yakovlev, A., & Guekht, A.  (2023). Functions of nonsuicidal self-injurious behavior in Russian patients with suicidal ideation. Frontiers in Public Health, 11, 1270944. https://doi.org/10.3389/fpubh.2023.1270944

Zinchuk, N.S., Avedisova, A.S., & Gekht, A.V. (2019). Nesuitsidal'noe samopovrezhdaiushchee povedenie pri psikhicheskikh rasstroistvakh nepsikhoticheskogo urovnia: epidemiologiia, sostoianie i klinicheskie faktory riska [Nonsuicidal self-injury behavior in non-psychotic disorders: epidemiology, social and clinical risk factors]. Zhurnal Nevrologii i Psikhiatrii imeni SS Korsakova [S.S. Korsakov Journal of Neurology and Psychiatry], 119(3), 108–119.https://doi.org/10.17116/jnevro2019119031108