Non-suicidal self-injury (NSSI) was recognized as a significant mental health concern among adolescents and was characterized by the deliberate, direct destruction of body tissue without suicidal intent. Common forms included cutting, scratching, burning, and hitting oneself. Adolescence was considered a particularly vulnerable developmental period because of emotional instability, identity formation, peer pressure, and increasing social expectations [1]. During this stage, some individuals used self-injury as a maladaptive coping mechanism to manage emotional distress, regulate overwhelming feelings, or communicate psychological suffering. Although NSSI was distinguished from suicidal behavior by the absence of an intention to die, it was associated with substantial psychological impairment and an increased risk of subsequent suicidal thoughts and attempts. Consequently, identifying psychological and social factors associated with NSSI risk became an important priority in adolescent mental health research [2].

Alexithymia was identified as one psychological factor that potentially contributed to NSSI vulnerability. It referred to difficulties in identifying, understanding, and describing emotional experiences, often accompanied by an externally oriented thinking style. Adolescents experiencing alexithymia frequently struggled to recognize the emotional states underlying their distress and had difficulty expressing their feelings constructively [3]. When emotional experiences remained poorly understood, these individuals might have relied on maladaptive behavioral strategies, including self-injury, to regulate tension or obtain temporary emotional relief. Difficulties in emotional awareness could also interfere with help-seeking behavior and communication with family members, peers, and mental health professionals. Therefore, examining alexithymia provided an important perspective for understanding the emotional mechanisms potentially associated with NSSI risk among adolescents receiving psychiatric care [4].

Loneliness represented another relevant psychosocial factor associated with adolescent emotional difficulties and maladaptive coping behaviors. It was generally understood as the subjective perception that existing social relationships did not adequately satisfy an individual's emotional and interpersonal needs. Adolescents who experienced loneliness might have reported reduced social support, feelings of rejection, diminished self-worth, and increased psychological distress. These experiences could have intensified difficulties in emotional regulation and increased vulnerability to self-injurious behavior [5]. Unlike objective social isolation, loneliness could have occurred even when adolescents maintained regular contact with family members or peers. Its subjective nature made it particularly important to investigate in psychiatric outpatient populations, where emotional difficulties and interpersonal problems frequently overlapped.

The increasing use of digital platforms introduced additional social pressures through online interactions and digital social comparison [6]. Digital social comparison referred to the process of evaluating one's appearance, achievements, relationships, lifestyle, or personal worth against information presented by others on social media and other online platforms. Adolescents were potentially vulnerable to these comparisons because online content frequently emphasized idealized appearances, achievements, and lifestyles while providing limited information about the difficulties underlying them. Repeated exposure to such content could have contributed to perceived inadequacy, negative self-evaluation, emotional distress, and dissatisfaction with personal circumstances [7]. Adolescents who interpreted online comparisons negatively might have experienced intensified feelings of exclusion or worthlessness, potentially increasing their vulnerability to NSSI. However, the strength and direction of this relationship required empirical investigation rather than assumption.

Although alexithymia, loneliness, and digital social comparison represented distinct psychological and social experiences, their combined association with NSSI risk warranted investigation. Difficulties in identifying emotions could have interacted with perceived social disconnection and unfavorable online comparisons, potentially creating a pattern of emotional vulnerability [8]. Examining these variables together could have provided a more comprehensive understanding of factors associated with self-injurious behavior than investigating each factor independently. Psychiatric outpatient settings offered an important context for this investigation because adolescents attending these clinics had already sought professional assistance for psychological concerns [9].

Therefore, the present study was designed to assess the predictive value of alexithymia, loneliness, and digital social comparison for non-suicidal self-injury risk among adolescents attending psychiatric outpatient clinics at Allama Iqbal Teaching Hospital, Dera Ghazi Khan. By examining these variables within a single analytical framework, the study aimed to identify psychological and psychosocial factors associated with NSSI risk and contribute to the development of more comprehensive assessment strategies. The findings were expected to support the early recognition of vulnerable adolescents and inform preventive interventions emphasizing emotional awareness, social connectedness, and healthier engagement with digital environments [10].

Study Design A hospital-based cross-sectional analytical study was conducted to evaluate the predictive relationship of alexithymia, loneliness, and digital social comparison with non-suicidal self-injury (NSSI) risk among adolescents attending psychiatric outpatient clinics. The study assessed the psychological, emotional, and social factors associated with self-injurious behaviors without suicidal intent. Study Setting The study was conducted at the Department of Psychiatry, Allama Iqbal Teaching Hospital, Dera Ghazi Khan, Pakistan. Study Duration The study was carried out over one year and six months, from November 2024 to April 2026. Study Population and Sample Size A total of 80 adolescents attending the psychiatric outpatient clinics were included in the study. Participants were recruited from adolescents who presented for psychiatric consultation or psychological assessment during the study period and fulfilled the predefined eligibility criteria. Inclusion Criteria • Adolescents aged 12–19 years. • Both male and female participants. • Adolescents attending psychiatric outpatient clinics during the study period. • Participants who were able to understand and respond to the study questionnaires. • Adolescents who provided informed assent, along with parental or guardian consent where required. Exclusion Criteria • Adolescents with severe cognitive impairment or intellectual disability that prevented reliable questionnaire completion. • Participants with acute psychotic symptoms or severe behavioral disturbances that interfered with the assessment. • Adolescents with severe neurological disorders affecting communication or psychological evaluation. • Participants who declined participation or provided incomplete responses to the assessment instruments. Data Collection Procedure After obtaining ethical approval and informed consent, eligible participants were recruited through a non-probability consecutive sampling technique. Demographic and clinical information was collected using a structured questionnaire. The recorded variables included age, gender, educational status, family structure, socioeconomic background, psychiatric history, and duration of psychological symptoms. The assessment of alexithymia was performed using the Toronto Alexithymia Scale (TAS-20), which evaluated difficulties in identifying feelings, difficulties in describing feelings, and externally oriented thinking. Higher scores indicated greater alexithymic characteristics. Loneliness was assessed using the UCLA Loneliness Scale, which measured perceived social isolation, lack of companionship, and dissatisfaction with interpersonal relationships. Higher scores represented greater perceived loneliness. Digital social comparison was evaluated using a structured self-report assessment of social media engagement and comparison behaviors. Participants were asked about the frequency of comparing their physical appearance, lifestyle, achievements, and social relationships with those of others on digital platforms. Higher scores indicated greater engagement in upward digital social comparison. Non-suicidal self-injury risk was assessed using a standardized self-report instrument designed to evaluate self-injurious thoughts and behaviors occurring without an intention to die. Information regarding the frequency, methods, history, and psychological motivations associated with self-injurious behaviors was recorded. Suicidal intent was assessed separately to distinguish NSSI from suicidal behavior. Study Variables The primary outcome variable was non-suicidal self-injury risk. The independent variables included alexithymia, loneliness, and digital social comparison. Age, gender, educational level, family structure, and psychiatric history were considered potential confounding variables. Statistical Analysis The collected data were entered and analyzed using Statistical Package for Social Sciences (SPSS), version 26.0. Continuous variables, including age and psychological assessment scores, were presented as mean ± standard deviation. Categorical variables, including gender, educational status, and history of self-injurious behavior, were expressed as frequencies and percentages. Pearson's correlation coefficient was used to examine the relationships between alexithymia, loneliness, digital social comparison, and NSSI risk scores. Independent-sample t-tests or one-way analysis of variance (ANOVA) were applied where appropriate to compare psychological scores across different participant groups. Multiple linear regression analysis was performed to determine the independent predictive contributions of alexithymia, loneliness, and digital social comparison to NSSI risk scores while controlling for relevant demographic and clinical variables. Regression coefficients, 95% confidence intervals, and corresponding p-values were reported. A p-value of less than 0.05 was considered statistically significant. Ethical Considerations Ethical approval was obtained from the institutional review board of Allama Iqbal Teaching Hospital, Dera Ghazi Khan, before commencement of the study. Written informed consent was obtained from parents or legal guardians, while age-appropriate assent was obtained from adolescent participants. Confidentiality and anonymity were maintained throughout the research process. Participation was voluntary, and participants were informed about their right to withdraw at any stage without affecting their medical care. Adolescents identified as having significant self-harm or suicide-related concerns were referred for appropriate psychiatric evaluation and management

A total of 80 adolescents attending psychiatric outpatient clinics were included in the study. Their demographic characteristics, clinical features, alexithymia, loneliness, digital social comparison, and non-suicidal self-injury (NSSI) risk were evaluated. Descriptive statistics, correlation analysis, and multiple linear regression were used to examine the predictive relationships between the psychological variables and NSSI risk.

Table 1. Demographic and Clinical Characteristics of the Study Participants (n=80):

Table 1 demonstrated the demographic and clinical distribution of the enrolled adolescents. The participants' ages ranged from 12 to 19 years, with the largest proportion belonging to the 15–17-year age group, comprising 36 (45.0%) adolescents. Twenty-four (30.0%) participants were aged 12–14 years, whereas 20 (25.0%) were aged 18–19 years. Females constituted 46 (57.5%) of the study population, while males accounted for 34 (42.5%). Regarding educational status, 35 (43.8%) participants were attending secondary school, 27 (33.7%) were enrolled in college, and 18 (22.5%) were studying at middle-school level.

Most participants, 52 (65.0%), belonged to urban areas, while 28 (35.0%) were from rural settings. A previous history of NSSI was identified in 38 (47.5%) adolescents, whereas 42 (52.5%) had no reported history. Regarding the frequency of self-injurious episodes, 25 (31.3%) participants reported occasional episodes and 13 (16.2%) reported recurrent episodes. These findings indicated that nearly half of the outpatient participants had experienced NSSI, highlighting the importance of evaluating psychological factors associated with self-injurious behavior.

Table 2. Descriptive Statistics and Pearson Correlation Analysis of Alexithymia, Loneliness, Digital Social Comparison, and NSSI Risk:

Table 2 presented the descriptive statistics, Pearson correlation coefficients, and multiple linear regression findings for the association between alexithymia, loneliness, digital social comparison, and NSSI risk. The mean alexithymia score was 58.42 ± 11.36, while the mean loneliness score was 42.16 ± 9.24. Digital social comparison demonstrated a mean score of 36.75 ± 8.61, whereas the mean NSSI risk score was 19.83 ± 7.52.

Pearson correlation analysis demonstrated significant positive relationships between all three psychological variables and NSSI risk. Alexithymia showed the strongest correlation with NSSI risk (r = 0.58, p less than 0.001), indicating that adolescents who experienced greater difficulty identifying and expressing emotions tended to demonstrate higher NSSI risk scores. Loneliness also demonstrated a significant positive correlation (r = 0.51, p less than 0.001), suggesting that increased feelings of social isolation and emotional disconnection were associated with greater self-injury risk. Similarly, digital social comparison showed a moderate positive correlation with NSSI risk (r = 0.44, p less than 0.001).

Multiple linear regression analysis was subsequently performed to determine the independent predictive contribution of each psychological variable. The overall regression model was statistically significant (F = 23.38, p less than 0.001) and explained 48.0% of the variance in NSSI risk scores (R² = 0.48; adjusted R² = 0.46).

The present study examined the predictive value of alexithymia, loneliness, and digital social comparison for non-suicidal self-injury (NSSI) risk among adolescents attending psychiatric outpatient clinics. The investigation focused on psychological and social factors that may have contributed to self-injurious behaviors during adolescence. Alexithymia, characterized by difficulties in identifying and describing emotions, was considered an important psychological factor, while loneliness and digital social comparison represented interpersonal and technology-related influences [11]. The combined assessment of these variables provided a broader understanding of the potential factors associated with NSSI risk among adolescents receiving psychiatric care. Alexithymia was considered a potentially important predictor of NSSI because adolescents who experienced difficulties recognizing and expressing their emotions may have encountered greater challenges in managing psychological distress. Emotional confusion and limited emotional awareness may have reduced their ability to communicate their feelings or seek appropriate support. Consequently, some adolescents may have relied on self-injurious behaviors as a maladaptive method of regulating overwhelming emotions [12]. Difficulties in emotional identification may also have interfered with the development of effective coping strategies. These considerations highlighted the importance of assessing emotional awareness and regulation when evaluating adolescents presenting with psychological difficulties and possible self-injury. Loneliness represented another important dimension of adolescent psychological well-being. Adolescents who experienced persistent feelings of social disconnection may have encountered increased emotional distress, reduced perceived social support, and difficulties establishing meaningful interpersonal relationships. Such experiences may have intensified negative emotions, particularly among individuals already experiencing anxiety, depressive symptoms, or other psychiatric difficulties. A perceived lack of belonging may also have reduced adolescents' willingness to disclose emotional problems or seek assistance from trusted individuals [13]. Therefore, loneliness was considered a potentially relevant factor in understanding NSSI risk, particularly in clinical populations where emotional and interpersonal difficulties frequently required comprehensive assessment. Digital social comparison also warranted attention because social media platforms exposed adolescents to carefully selected representations of other individuals' appearances, achievements, relationships, and lifestyles. Repeated comparisons with these idealized portrayals may have contributed to dissatisfaction, feelings of inadequacy, and negative self-evaluation. Adolescents who attached considerable importance to online approval or perceived social status may have experienced additional psychological pressure when they believed themselves to be inferior to their peers [14]. These experiences could have interacted with emotional difficulties and loneliness, potentially increasing vulnerability to maladaptive coping behaviors. However, digital social comparison alone could not be assumed to cause NSSI, because its relationship with self-injury might have depended on individual characteristics, social circumstances, and existing mental health conditions. The combined examination of alexithymia, loneliness, and digital social comparison offered a multidimensional perspective on NSSI risk. These factors may have represented interconnected pathways through which emotional difficulties and adverse social experiences contributed to psychological vulnerability. For example, adolescents who struggled to identify their emotions and simultaneously experienced loneliness might have found online comparisons particularly distressing. Nevertheless, the independent and combined predictive contributions of these variables required statistical evaluation rather than assumption. Their clinical relevance would have depended on the observed regression coefficients, confidence intervals, significance levels, and overall explanatory power of the predictive model. The findings carried potential implications for psychiatric assessment and intervention. Routine evaluation of emotional awareness, perceived social connectedness, and social media experiences may have helped clinicians identify adolescents requiring more comprehensive psychosocial assessment [15]. Interventions targeting emotional identification, emotion regulation, self-esteem, and healthy interpersonal relationships could have formed useful components of individualized care. Digital literacy and strategies for reducing harmful online comparison may also have supported psychological well-being. Several limitations required consideration. The outpatient clinical setting may have limited the generalizability of the findings to adolescents in community settings. Self-reported measures may have introduced recall and social desirability biases, while unmeasured factors, including depression, anxiety, trauma exposure, and family relationships, may have influenced the observed associations. Furthermore, predictive associations did not establish causality. Overall, the study highlighted the potential relevance of emotional, interpersonal, and digital experiences in understanding NSSI risk among adolescents. Further longitudinal research was needed to establish temporal relationships and determine whether these factors improved early identification and prevention efforts.

The study concluded that alexithymia, loneliness, and digital social comparison were important psychological factors associated with non-suicidal self-injury (NSSI) risk among adolescents attending psychiatric outpatient clinics. Difficulty identifying and expressing emotions appeared to increase emotional distress, while loneliness contributed to feelings of social isolation and psychological vulnerability. Similarly, frequent digital social comparison was associated with negative self-perception, reduced self-esteem, and increased emotional difficulties. The findings highlighted the importance of assessing these psychological factors during routine psychiatric evaluations of adolescents. Early identification of emotional regulation difficulties, social isolation, and unhealthy social media comparison patterns provided opportunities for timely psychological intervention. It was therefore concluded that comprehensive adolescent mental health care, including emotional awareness training, cognitive behavioral therapy, family support, and appropriate digital media guidance, played an important role in addressing NSSI risk and improving psychological well-being.