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A Study of Self-Harm Behavior

Informed Consent for Research Participation
Investigator: Liz Floto, [email protected]

Read this consent form. The Department of Psychology supports the practice of protection for human participants in research and related activities. The following information is provided so that you can decide whether you wish to participate in the present study. You should be aware that even if you agree to participate, you are free to withdraw at any time, and that if you do withdraw from the study, you will not be subjected to reprimand or any other form of penalty.

This survey is on the subject of self-harm behaviors and personal attributes. You are being asked to complete the questionnaire. It should not take you longer than 20 to 35 minutes to complete, and you may enter into a drawing to win a $50 Visa debit card.

These questionnaires are to be completed anonymously, and your participation is completely voluntary. All data submitted will be given and ID number that is not linked to you identity. Your personal information will be kept confidential, and you are encouraged to answer each question honestly. No individual data will be analyzed; the data is being used to find general correlations between groups. As experimenters, we have no foreseen harm that could be caused to participants. You are reminded that you are free to withdraw at any time from the experiment with no repercussions.
If you have and questions, concern or comments about the study or the informed consent process, please contact Liz Floto, [email protected]. The results of this study will be posted in May of 2009 at

www.csucresearch.blogspot.com.

I understand that by clicking "yes" below acts as my signature. I acknowledge that I have received a description of my participation in this study, and that I have read and understood the description, and that I am voluntarily agreeing to participate in this research. I am aware that may choose to end my participation in this study at anytime without penalty. I also acknowledge that I am at least 18 years old.

How old are you?
Please select your gender
Have you ever been diagnosed by a professional as having a mental disorder? These may include such things as borderline personality disorder, schizophrenia, post tramatic stress disorder, obsessive compulsive disorder, a mood disorder or other impulse disorder. The definition of a professional is a practitioner with either a medical degree,(MD), PhD, or PsyD.
If you have been diagnosed, please type your diagnosis or diagnoses below.
Instructions: Please answer the following questions by checking either, “Yes”, or “No.” Check “yes” only to those items that you have done intentionally, or on purpose, to hurt yourself.Please choose "yes" even if these actions were in the past.

Cut yourself on purpose?
How old were you when you cut yourself most often? You may choose multiple answers.
Instructions: Please answer the following questions by checking either, “Yes”, or “No.” Check “yes” only to those items that you have done intentionally, or on purpose, to hurt yourself.Please choose "yes" even if these actions were in the past.

Burned yourself on purpose?
How old were you when you burned yourself most often? You may choose multiple answers.
Instructions: Please answer the following questions by checking either, “Yes”, or “No.” Check “yes” only to those items that you have done intentionally, or on purpose, to hurt yourself.Please choose "yes" even if these actions were in the past.

Hit yourself, or slammed arms/legs against objects ?
How old were you when you hit yourself most often? You may choose multiple answers.
Instructions: Please answer the following questions by checking either, “Yes”, or “No.” Check “yes” only to those items that you have done intentionally, or on purpose, to hurt yourself.Please choose "yes" even if these actions were in the past.

Banged your head on purpose?
How old were you when you banged you head most often? You may choose multiple answers.
Instructions: Please answer the following questions by checking either, “Yes”, or “No.” Check “yes” only to those items that you have done intentionally, or on purpose, to hurt yourself.Please choose "yes" even if these actions were in the past.

Scratched yourself on purpose?
How old were you when you scratched yourself most often? You may choose multiple answers.
Instructions: Please answer the following questions by checking either, “Yes”, or “No.” Check “yes” only to those items that you have done intentionally, or on purpose, to hurt yourself.Please choose "yes" even if these actions were in the past.

Prevented wounds from healing?
How old were you when you prevented wounds from healing most often? You may choose multiple answers.
Instructions: Please answer the following questions by checking either, “Yes”, or “No.” Check “yes” only to those items that you have done intentionally, or on purpose. Please choose "yes" even if these actions were in the past.

Choked yourself? (this includes using objects such as belts or rope)
How old were you when you choked yourself most often? You may choose multiple answers.
Instructions: Please answer the following questions by checking either, “Yes”, or “No.” Check “yes” only to those items that you have done intentionally, or on purpose. Please choose "yes" even if these actions were in the past.

Allowed another person to choke you. This includes playing the “Choking Game”, “Space Monkey” or “Cloud Nine”.
How old were you when you let others choke you most often? You may choose multiple answers.
Have you engaged in any other self-destructive behaviors not asked about in this inventory? If so, please describe below.
If you answered yes to any of the above statements, were any of the acts done with a suicidal intent? In other words did you intend to end your life with any behavior mentioned above?
Please read each statement and indicate how the statement applied to you over the past week. There are no right or wrong answers. Do not spend too much time on any statement.

.
Did not apply to me at all
Applied to me to some degree, or some of the time
Applied to me to a considerable degree, or a good part of the time
Applied to me very much, or most of the time
I found myself getting upset by quite trivial things.
I was aware of dryness of my mouth.
I couldn’t seem to experience any positive feeling at all.
I experienced breathing difficulty (e.g., excessively rapid breathing, breathlessness in the absence of physical exertion).
I just couldn’t seem to get going.
I tended to overreact to situations.
I had a feeling of shakiness (e.g., legs going to give way).
I found it difficult to relax.
Please read each statement and indicate how the statement applied to you over the past week. There are no right or wrong answers. Do not spend too much time on any statement.

.
Did not apply to me at all
Applied to me to some degree, or some of the time
Applied to me to a considerable degree, or a good part of the time
Applied to me very much, or most of the time
I found myself in situations that made me so anxious I was most relieved when they ended.
I felt that I had nothing to look forward to.
I found myself getting upset rather easily.
I felt that I was using a lot of nervous energy.
I felt sad and depressed.
I found myself getting impatient when I was delayed in any way (e.g., elevators, traffic lights, being kept waiting).
I had a feeling of faintness.
I felt that I had lost interest in just about everything.
Please read each statement and indicate how the statement applied to you over the past week. There are no right or wrong answers. Do not spend too much time on any statement.

.
Did not apply to me at all
Applied to me to some degree, or some of the time
Applied to me to a considerable degree, or a good part of the time
Applied to me very much, or most of the time
I felt I wasn’t worth much as a person.
I felt that I was rather touchy.
I perspired noticeably (e.g., hands sweaty) in the absence of high temperatures or physical exertion.
I felt scared without any good reason.
I felt that life wasn’t worthwhile.
I found it hard to wind down.
I had difficulty in swallowing.
I couldn’t seem to get any enjoyment out of the things I did.
Please read each statement and indicate how the statement applied to you over the past week. There are no right or wrong answers. Do not spend too much time on any statement.

.
Did not apply to me at all
Applied to me to some degree, or some of the time
Applied to me to a considerable degree, or a good part of the time
Applied to me very much, or most of the time
I was aware of the action of my heart in the absence of physical exertion (e.g., sense of heart rate increase, heart missing a beat).
I felt downhearted and blue.
I found that I was very irritable.
I felt I was close to panic.
I found it hard to calm down after something upset me.
I feared that I would be “thrown” by some trivial but unfamiliar task.
I was unable to become enthusiastic about anything.
I found it difficult to tolerate interruptions to what I was doing.
Please read each statement and indicate how the statement applied to you over the past week. There are no right or wrong answers. Do not spend too much time on any statement.

.
Did not apply to me at all
Applied to me to some degree, or some of the time
Applied to me to a considerable degree, or a good part of the time
Applied to me very much, or most of the time
I was in a state of nervous tension.
I felt I was pretty worthless.
I was intolerant of anything that kept me from getting on with what I was doing.
I felt terrified.
I could see nothing in the future to be hopeful about.
I felt that life was meaningless.
I found myself getting agitated.
I was worried about situations in which I might panic and make a fool of myself.
I experienced trembling (e.g., in the hands).
I found it difficult to work up the initiative to do things.
For the following items please rate how characteristic each is of you. Using the following rating scale record your answer that fits best.


Extremely uncharacteristic of me
Somewhat uncharacteristic of me
Only slightly characteristic of me
Somewhat characteristic of me
Extremely characteristic of me
1. Once in a while I can’t control the urge to strike another person.
2. I tell my friends openly when I disagree with them.
3. I flare up quickly but get over it quickly.
4. I am sometimes eaten up with jealousy.
5. Given enough provocation, I may hit another person.
6. I often find myself disagreeing with people.
7. When frustrated, I let my irritation show.
8. At times I feel I have gotten a raw deal out of life.
9. If somebody hits me; I hit back.
10. When people annoy me, I may tell them what I think of them.
For the following items please rate how characteristic each is of you. Using the following rating scale record your answer that fits best.


Extremely uncharacteristic of me
Somewhat uncharacteristic of me
Only slightly characteristic of me
Somewhat characteristic of me
Extremely characteristic of me
11. I sometimes feel like a powder keg ready to explode.
12. Other people always seem to get the breaks.
13. I get into fights a little more than the average person.
14. I can’t help getting into arguments when people disagree with me.
15. Some of my friends think I’m a hothead.
16. I wonder why sometimes I feel so bitter about things.
17. If I have to resort to violence to protect my rights, I will.
18. My friends say that I’m somewhat argumentative.
19. Sometimes I fly off the handle for no good reason.
20. I know that “friends” talk about me behind my back.
For the following items please rate how characteristic each is of you. Using the following rating scale record your answer that fits best.


Extremely uncharacteristic of me
Somewhat uncharacteristic of me
Only slightly characteristic of me
Somewhat characteristic of me
Extremely characteristic of me
21. There are people who pushed me so far that we came to blows.
22. I have trouble controlling my temper.
23. I am suspicious of overly friendly strangers.
24. I can think of no good reason for ever hitting a person.
25. I sometimes feel that people are laughing at me behind my back.
26. I have threatened people I know.
27. When people are especially nice, I wonder what they want.
28. I have become so mad that I have broken things.
29. I am an even-tempered person.
People differ in the ways they act and think in different situations. This is a test to measure some of the ways in which you act and think. Read each statement and choose a response that most describes you. Do not spend too much time on any statement. Answer quickly and honestly.



.
Rarely/Never
Occasionally
Often
Almost Always/Always
1. I plan tasks carefully.
2. I do things without thinking.
3. I am happy-go-lucky.
4. I have “racing” thoughts.
5. I plan trips well ahead of time.
6. I am self-controlled.
7. I concentrate easily.
8. I save regularly.
9. I find it hard to sit still for long periods of time.
10. I am a careful thinker.
People differ in the ways they act and think in different situations. This is a test to measure some of the ways in which you act and think. Read each statement and choose a response that most describes you. Do not spend too much time on any statement. Answer quickly and honestly.



.
Rarely/Never
Occasionally
Often
Almost Always/Always
11. I plan for job security.
12. I say things without thinking.
13. I like to think about complex problems.
14. I change jobs.
15. I act “on impulse.”
16. I get easily bored when solving thought problems.
17. I have regular medical/dental checkups.
18. I act on the spur of the moment.
19. I am a steady thinker.
20. I change where I live.
People differ in the ways they act and think in different situations. This is a test to measure some of the ways in which you act and think. Read each statement and choose a response that most describes you. Do not spend too much time on any statement. Answer quickly and honestly.



.
Rarely/Never
Occasionally
Often
Almost Always/Always
21. I buy things on impulse.
22. I finish what I start.
23. I walk and move fast.
24. I solve problems by trial-and-error.
25. I spend or charge more than I earn.
26. I talk fast.
27. I have outside thoughts when thinking.
28. I am more interested in the present than the future.
29. I am restless at lectures or talks.
30. I plan for the future.
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