The efficacy of cognitive behavioral therapy (CBT) in improving emotion regulation and self-injurious behavior in adolescents with non-suicidal self-injury (NSSI)

The efficacy of cognitive behavioral therapy (CBT) in improving emotion regulation and self-injurious behavior in adolescents with non-suicidal self-injury (NSSI) | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The efficacy of cognitive behavioral therapy (CBT) in improving emotion regulation and self-injurious behavior in adolescents with non-suicidal self-injury (NSSI) Zixuan Guo, Jun Liu, Qiuyu Chen, Li Zhu, Sisi Xie, Chunyan Zhu, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9392047/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 9 You are reading this latest preprint version Abstract Background: Non-suicidal self-injury (NSSI) is prevalent among adolescents and is associated with emotion regulation deficits. This study aimed to examine the effects of group cognitive behavioral therapy (G-CBT) on emotion regulation in adolescents with NSSI disorder and whether enhanced emotion regulation ability could reduce NSSI behaviors. Method: Participants were adolescents with NSSI disorder (G-CBT: n = 27; Control: n = 27). In addition to standard pharmacotherapy, the G-CBT group underwent eight sessions of G-CBT, twice a week. The control group received pharmacotherapy only. Clinical scales and eye-tracking data was collected before and after the intervention. The primary outcomes were NSSI frequency, with secondary outcomes including emotion regulation, eye-tracking indices, depression and alexithymia. Results: In contrast to the control group, the G-CBT group indicated a significant reduction in NSSI frequency and depressive symptoms after intervention, along with marked improvements in emotion regulation and alexithymia. Eye-tracking results showed that during cognitive reappraisal, the G-CBT group exhibited longer gaze durations toward negative stimuli, particularly in the early (0-1500 ms) and late (2000-4000 ms) stages, reflecting enhanced emotional engagement. Furthermore, higher baseline levels of externally oriented thinking (EOT) predicted poorer improvement in NSSI behaviors following G-CBT. Conclusions: These findings suggest that G-CBT may be effective in reducing NSSI behaviors and improving emotion regulation, with EOT representing a potential therapeutic target. Clinical Trial Registration: Chinese Clinical Trial Registry (ChiCTR2500103826). Non-suicidal self-injury Emotion regulation Reappraisal Group Cognitive-Behavioral Therapy Eye-tracking Figures Figure 1 Figure 2 Figure 3 Highlights G-CBT may be effective in reducing NSSI behaviors and improving emotion regulation. The improvement of reappraisal processes is continuous after G-CBT. A higher level of EOT predicts poorer improvement in NSSI behaviors after intervention. 1. Introduction Non-suicidal self-injury (NSSI) is the direct and deliberate destruction of body tissue without the intent to die (Nock, 2010 ). Worldwide, the aggregate estimate of the 12-month prevalence of NSSI is 19.5% (Lim et al., 2019 ). Adolescence is a vulnerable period for developing NSSI (Muehlenkamp, Xhunga, & Brausch, 2019 ). The typical onset of NSSI occurs at age 12 (Cipriano, Cella, & Cotrufo, 2017 ) and it peaks at between 15-and 17-years-old (Plener, Schumacher, Munz, & Groschwitz, 2015 ). Converging results show that NSSI is a high risk factor for later suicide attempts (Griep & MacKinnon, 2020 ) and behaviors (Whitlock et al., 2013 ). Past studies have illustrated that NSSI was strongly associated with emotion dysregulation. Specifically, greater emotion regulation deficits are related to higher rates of NSSI (Wolff et al., 2019 ). Although NSSI provides relief from negative affect (Klonsky, 2009 ), deterioration of emotions follows (Koenig et al., 2020 ). Therefore, considering the potential risks and short-term benefits of NSSI, developing the ability to regulate emotions is of great significance for alleviating NSSI in adolescents. Emotion regulation, whether up- or down-regulation, aims to influence our or others’ current emotional states (Gross, 2002 ). Emotion regulation strategy is a vast family tree that includes cognitive reappraisal, distraction, and expressive suppression (McRae & Gross, 2020 ). According to Gross’s process model, emotion regulation involves multiple-stage processes: an event or stimulus, distribution of attention, assessing the event through appraisal, and responding to the event (Gross, 1998 ). Experiencing failure in a certain phase of the model, such as attentional bias to stimuli, suppressing emotions, or failing to use effective reappraisal, can result in the failure or dysregulation of emotion regulation, which ultimately leads to the development of maladaptive coping strategies such as NSSI (Gross, 2015 ). Among adolescents with NSSI disorder, relieving negative emotions is the primary purpose of engaging in NSSI (P. J. Taylor et al., 2018 ). NSSI is therefore conceptualized as a maladaptive emotion regulation strategy (Nock, 2010 ). Among emotion regulation strategies, cognitive reappraisal is typically associated with positive consequences (Kivity & Huppert, 2016 ; McRae & Gross, 2020 ). However, adolescents who engage in NSSI are poor at using reappraisal to regulate negative emotions (Wolff et al., 2019 ). Compared to non-NSSI adolescents, adolescents with NSSI disorder reported using less active reappraisal (Hauber, Boon, & Vermeiren, 2019 ), and this related to a higher NSSI risk within twelve months (Voon, Hasking, & Martin, 2014 ). In addition, adolescents with NSSI disorder usually experience uncontrolled negative emotions (Kranzler et al., 2018 ), and it is harder to use reappraisal effectively in highly intensive situations (Kranzler et al., 2018 ; Raio, Orederu, Palazzolo, Shurick, & Phelps, 2013 ). Surprisingly, another frequently-used emotion regulation strategy, distraction, failed to prevent adolescents from engaging in NSSI behaviors (Koenig et al., 2020 ). Improving the ability to modify emotion is therefore an important therapeutic intervention target in NSSI disorder clinic practice (Gratz, 2007 ). Of note, attention is fundamental to both cognitive reappraisal and distraction. According to the modal model of emotion, regulating emotional responses involves both attentional focusing (concentration) and shifting (distraction). Crucially, because emotional responses evolve and stimuli can be highly provocative, effective reappraisal demands sustained attention and effort (Chung, Heakes, & Kaufman, 2023 ; Kalisch, 2009 ; Kalisch et al., 2011 ; Wang, Li, Li, & Chen, 2024 )(page R2 2First). Therefore, cognitive reappraisal requires more attentional resources, specifically an increase in gaze time to emotional stimulus throughout the entire reappraisal process. CBT is listed as the first-line treatment for adolescent depression and anxiety disorders (Rith-Najarian et al., 2019 ), and convincing evidence supports its positive role in improving emotion regulation skills (Daros et al., 2021 ). It is important to note that CBT is also an efficient therapeutic approach for adolescents with NSSI disorder (Iyengar et al., 2018 ). Several manualized and specially developed CBT studies involve cultivating adaptive emotion regulation skills that need to be highlighted (Edinger et al., 2020 ; Fischer, Brunner, Parzer, Resch, & Kaess, 2013 ; Hogberg & Hallstrom, 2018 ; Kaess et al., 2020 ). A flexible manual CBT intervention (8–12 intervention sessions) showed a greater decrease in the frequency of NSSI and depression among adolescents in the CBT group after the treatment (Fischer et al., 2013 ). Notably, another study demonstrated that CBT led to significantly reduced depressive symptoms and altered attentional biases which was strongly associated with maintenance of gaze (Vazquez et al., 2018 ). However, mixed results were exhibited for the subsequent two manualized CBT interventions for adolescents with NSSI disorder (Edinger et al., 2020 ; Kaess et al., 2020 ). One possible explanation is that, for adolescents who engage in NSSI, more efforts may need to be focused on emotion regulation(Gratz, 2007 ; Sahlin et al., 2017 ). Eye-tracking methodology is commonly used to analyze the typical gaze pattern of individuals with affective disorders (Armstrong & Olatunji, 2012 ). As a general rule, the eye movements reflect the mental processing course of cognitive and emotional states, regardless of what we are looking at in any given time (Carter & Luke, 2020 ). Fixation time and fixation count are frequently used eye-tracking indicators, representing the attentional allocation changes of different stages in information processing (Skaramagkas et al., 2021 ). It is worth noting that the advantage of eye-tracking in temporal sensitivity provides a moment-by-moment insight into potential cognition instead of just showing final results (Carter & Luke, 2020 ). A recent eye-tracking study found that CBT treatment encouraged depressed individuals to spend more time watching positive face images (Vazquez et al., 2018 ). After sixteen sessions of CBT, the difference between children with separation anxiety disorder and non-anxious children no longer existed in the post-assessment using eye tracking, indicating the efficacy of the CBT treatment (In-Albon, Ruf, & Schmid, 2015 ). To date, there are few studies on changes in eye gaze towards emotional stimuli during emotion regulation following CBT intervention in adolescents with NSSI disorder. The present study aimed to evaluate the efficacy of G-CBT in adolescents with NSSI disorder. First, we hypothesized that, compared with the control condition (medication only), adolescents receiving G-CBT would show a greater reduction in NSSI behaviors at post-intervention (primary outcome). Second, we hypothesized that G-CBT would lead to improvements in emotion regulation (secondary outcomes), as reflected in both self-report measures (Emotion Regulation Questionnaire, ERQ) and eye-tracking indices under reappraisal and distraction conditions. Specifically, participants in the G-CBT group were expected to exhibit longer gaze duration toward negative stimuli during reappraisal. Furthermore, we expected that depressive symptoms, anxiety symptoms, and alexithymia would decrease following the intervention. Finally, we explored whether baseline alexithymia would predict treatment outcomes. 2. Methods We conducted a parallel-group randomised controlled trial (RCT) with pre- and post-intervention assessments. Participants were assessed at baseline prior to the intervention and again immediately after completion of the 4-week intervention. Figure 1 shows the study design and summarizes participant flow. 2.1. Participants A priori power analyses was performed with G*Power (v.3.1.9.7). For a within-between interaction effect in a repeated-measures ANOVA (2 groups × 2 time points), assuming a medium effect size (Cohen’s f = 0.25), an alpha of 0.05 (two-sided), and a power of 0.80, the analysis indicated that a total sample size of 34 participants (17 per group) was necessary. Considering an anticipated attrition rate of approximately 30%, a total of 54 participants were recruited to ensure adequate statistical power. A total of 72 adolescents were screened, of whom 54 met the eligibility criteria and consented to participate. Participants were recruited from the First Affiliated Hospital of Anhui Medical University and the Anhui Mental Health Center from February to November 2022. Inclusion criteria were: (1) age 12–18 years; (2) diagnosis of NSSI disorder based on the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition) and NSSI in the past two weeks; and (3) reported normal or corrected vision through glasses or contact lenses. Participants were not included if they had: (1) attempted suicide or current suicide plans; (2) acute psychotic symptoms; (3) impaired cognitive function; (4) received extra psychotherapeutic intervention; and (5) inability to understand and interact in Chinese. 2.2. Randomization and Masking Participants were randomly assigned in a 1:1 ratio to either the G-CBT group or the control group. Randomization was conducted by an independent researcher not involved in recruitment, assessment, or intervention delivery, using a computer-generated random sequence. Participants were blinded to group assignment, while therapist, due to the nature of the psychological intervention, were not. However, outcome assessors were blinded to group allocation to minimize assessment bias. 2.3. Intervention All participants continued their regular medication during the study period. Each individual took 50–150 mg of sertraline (50 mg per tablet) daily. Moreover, 12 individuals took 50 mg of quetiapine (25 mg per tablet). G-CBT Group In addition to their usual medication, participants in the G-CBT condition received eight sessions that were developed to reduce NSSI. The protocol integrated the literature with the proposals of several professionals in CBT. The content of the intervention for adolescents with NSSI disorder targets emotion regulation. The therapist received 3 days of training on treatment protocols and participated in weekly supervised meetings that were chaired by expert licensed psychologists. To maintain the integrity of treatment, the therapist followed a standardized protocol. All intervention sessions were audio-recorded, and a random subset of recordings was independently reviewed by licensed clinical psychologists using a manual-based adherence checklist to evaluate consistency with the protocol. For details about the protocol, see the Supplementary Materials. Control Group Participants in the control group received usual medication, which consisted of regular medication management, routine clinical monitoring, and psychoeducation, but did not receive any structured psychotherapy or behavioral interventions targeting NSSI and emotion regulation during the study period. 2.4. Measures 2.4.1. Primary outcome measure The primary outcome of this study was the change in NSSI behaviors, assessed using the Adolescent Non-suicidal Self-injury Assessment Questionnaire (ANSAQ). The ANSAQ (Yuhui., Wan., Jiahu., & Fangbiao., 2018) was developed based on the Functional Assessment of Self-Mutilation. This scale consists of 31 items, comprising behavioral subscales (12 items) and functional subscales (19 items). The behavioral subscales are divided into two dimensions (a) tissue damage (e.g., Deliberately cutting yourself) and (b) no tissue damage (e.g., Deliberately hitting a hard object with your head). The ANSAQ was administered to assess the frequency of NSSI behaviors during the preceding 2 weeks. 2.4.2. Secondary outcome measures Emotion Regulation Questionnaire (ERQ) The ERQ, was developed by Gross et al. (Gross & John, 2003 ) to assess the habitual use of emotion regulation strategies. The two subscales are cognitive reappraisal (six items) and expressive suppression (four items). Items are presented on a seven-point Likert scale (1–7) from strongly disagree to strongly agree. In the present study, the internal consistency of the ERQ was high, with Cronbach’s α values of 0.944 for the reappraisal subscale and 0.946 for the suppression subscale. The Cronbach’s α for the total scale was 0.801. Eye-tracking measure Eye-tracking indices (e.g., fixation duration, fixation count) during emotion regulation tasks were collected to provide an objective measure of attentional deployment. Hamilton Rating Scale for Depression (HAMD-17) The HAMD-17 (Hamilton, 1960 ) was administered, to evaluate the severity of depressive symptoms on a five-point Likert scale (0–4). Total scores ranged from 0 to 68. In the current sample, the scale demonstrated good internal consistency, with a Cronbach’s α of 0.920. Hamilton Rating Scale for Anxiety (HAMA-14) The HAMA is a 14-item measure (Hamilton, 1959 ) on a five-point Likert scale (0–4). It addresses both psychological and somatic symptoms. The Cronbach’s α was 0.884 within the sample. Chinese translation of the 20-item Toronto Alexithymia Scale (TAS-20-C) The TAS-20-C is a 20-item self-rated questionnaire used to assess alexithymia, including the three factors difficulty identifying feelings (F1), difficulty describing feelings (F2), and externally oriented thinking (F3). Each item is assessed on a five-point Likert scale (1–5), and five items are scored in reverse. In general, total scores ≥ 61 represent high alexithymia, while scores ≤ 51 indicate the absence of alexithymia (G. J. Taylor, Parker, Bagby, & Bourke, 1996 ). The scale has good reliability and validity in Chinese adolescents (Ling, Zeng, Yuan, & Zhong, 2016 ). In the current sample, Cronbach's alphas were 0.810 for F1, 0.804 for F2 and 0.702 for F3. The Cronbach’s α for the total scale was 0.818. All measures above were administered immediately before and after the intervention. 2.5. Eye-tracking paradigm Eye movements were recorded using a remote infrared eye-tracking system (iView X RED250; SensoMotoric Instruments, Germany) and analyzed with BeGaze software. The system sampled gaze data at 250 Hz. Stimuli were presented on a 22-inch monitor with a screen resolution of 1,920 × 1,080 pixels. A standard five-point calibration procedure was conducted prior to the task, and calibration was accepted when the average error was < 1° of visual angle. Fixations were identified using the default BeGaze fixation detection algorithm based on a velocity-threshold identification method, with a minimum duration of 100 ms and a maximum dispersion of 1° of visual angle. For details on how to select visual materials and determine areas of interest, see see the Supplementary Materials. Raw eye-tracking data were preprocessed before analysis. Periods of signal loss, blinks, and other artifacts were automatically detected and removed by the software. Trials with more than 20% missing samples were excluded, and only valid fixation data were included in the final analyses. 2.6. Data analysis SPSS 22.0 was used for statistical analysis. We used chi-square and t -tests to compare the demographic characteristics of the two groups before G-CBT. To analyze the effects of G-CBT on eye movement of emotional areas of interest (e-AOI) before and after the intervention, we performed 2 × 2 × 3 repeated-measures ANOVA. When a significant interaction was observed, we conducted an independent-sample t -test to make a comparison. Additionally, we utilized a temporal-course analysis to explore the detailed changes in the eye gaze on negative images over time between the two groups. Based on previous eye-tracking studies examining emotional gaze processing (Zhao et al., 2022 ), each 4-second image presentation was segmented into eight 500-millisecond segments. We employed a 2 × 3 × 8 repeated-measures ANOVA, with group (2: G-CBT and Controls) as a between-subject variable and task types (3: view negative, reappraisal, and distraction) and course (0-4000 ms) as within-subject variables. Moreover, to examine the changes in valence and arousal, we employed 2 × 4 repeated-measures ANOVA. A series of 2 × 2 repeated-measures ANOVAs were used to examine the effects of G-CBT on ERQ, depression, anxiety, and NSSI frequency before and after the intervention. Correlation analyses were conducted to test the associations between variables of interest and NSSI behaviors. For multiple comparisons, Bonferroni corrections were applied to control for Type I error. Effect sizes were reported as partial η 2 (η) for all ANOVA analyses. When the assumption of sphericity was violated, Greenhouse–Geisser corrections were applied. A two-tailed p value < 0.05 was considered statistically significant. Missing data were handled using listwise deletion. Participants with incomplete data on variables required for a given analysis were excluded from that analysis. 3. Results 3.1. Demographic characteristics Table 1 shows the demographic and clinical characteristics. All comparisons were insignificant. Table 1 Demographic and clinic characteristics Variable G-CBT(n = 22) Control(n = 20) t\ χ 2 p Age M(SD) 15.41(1.563) 15.45(2.114) -0.072 0.943 Gender (M/F) 7/15 5/15 0.239 0.625 Education M(SD) 9.00(1.746) 9.15(2.033) -0.257 0.798 MoCA M(SD) 28.14(2.678) 27.55(2.064) 0.789 0.435 HAMD M(SD) 25.50(5.466) 24.40(5.072) 0.674 0.504 HAMA M(SD) 24.27(5.650) 22.10(5.721) 1.237 0.223 TAS-20 M(SD) 67.45(5.449) 64.50(8.727) 1.329 0.191 ERQ-R M(SD) 20.41(5.901) 20.55(7.244) -0.069 0.945 ERQ-S M(SD) 19.59(3.887) 18.75(5.711) 0.562 0.577 Note: M: mean; SD, standard deviation; G-CBT, group cognitive-behavioral therapy; MoCA: Montreal cognitive assessment; HAMD, Hamilton Rating Scale for Depression; HAMA, Hamilton Anxiety Scale; TAS-20, Chinese translation of the 20-item Toronto Alexithymia Scale; ERQ, Emotion Regulation Questionnaire (R: cognitive reappraisal; S: expressive suppression). 3.2. Treatment adherence and attrition In the G-CBT group, two participants withdrew after attending three to four sessions due to perceived inefficacy, reporting that they did not perceive sufficient progress and had expected faster symptom relief. One additional participants discontinued due to poor attendance, primarily related to logistical barriers such as scheduling conflicts, or transportation difficulties; none reported dissatisfaction with the intervention content. Two further participants were excluded from the analysis at posttreatment assessment because they failed to provide eye-tracking data. In the control group, seven participants refused to complete the post-intervention assessment, with reasons including lack of direct incentive to complete follow-up measures (n = 2), fatigue from the baseline assessment (n = 2), and being unreachable despite multiple contact attempts (n = 3). Attrition analyses comparing study completers to non-completers on age, gender, NSSI frequency, depressive symptoms, anxiety symptoms, alexithymia, and emotion regulation, revealed no significant group differences. The final analyzed sample consisted of 22 participants in the G-CBT group (7 males and 15 females, M age = 15.41, SD = 1.563) and 20 participants in the control group (5 males and 15 females, M age = 15.45, SD = 2.114). 3.3. Primary outcome: Frequency of NSSI There were insignificant group × time interactions observed in total NSSI ( F (1, 40) = 2.745, p = .105, η = 0.064) and no tissue damage ( F (1, 40) = 1.868, p = .179, η = 0.045). The ANOVA for tissue damage displayed that the group (2: G-CBT and Control) × time (2: pretreatment and posttreatment) interaction was marginally significant ( F (1, 40) = 3.563, p = .066, η = 0.082). A follow-up independent-simple t-test showed that the G-CBT group had decreased NSSI frequency in comparison with the controls ( p = .017) after the treatment (see Fig. 2 a). 3.4. Secondary outcome 3.4.1. Valence and arousal Repeated-measures ANOVA (group × task types) revealed a significant main effect of task type ( F (3, 120) = 21.373, p < .001, η = 0.348) and group ( F (1, 40) = 7.263, p = .010, η = 0.154) on valence. There was a significant interaction between group and task type ( F (3, 120) = 5.682, p = .002, η = 0.124). Post-hoc comparisons with Bonferroni correction showed that valence ratings were significantly higher in the G-CBT group than in the control group under the reappraisal ( p = .002) and distraction ( p = .011) conditions. These findings indicate that adolescents with NSSI disorder demonstrated improved emotional evaluations of negative images following G-CBT intervention. 3.4.2. Emotion Regulation Questionnaire Repeated-measures ANOVA was conducted on reappraisal, with time as a within-subject factor and group as a between-subject factor. The results showed that an insignificant main effect of group ( F (1, 40) = 0.810, p = .374, η = 0.020) and a significant main effect of time ( F (1, 40) = 6.328, p = .016, η = 0.137) emerged. The results showed that the interaction ( F (1, 40) = 0.938, p = .338, η = 0.023; see Fig. 2 b. A) was insignificant. For suppression, a 2 × 2 repeated-measures ANOVA revealed that the main effects of group ( F (1, 40) = 4.188, p = .047, η = 0.095) was significant, but the main effects of time ( F (1, 40) = 3.285, p = .077, η = 0.076) were insignificant. There was a significant group × time interaction ( F (1, 40) = 5.430, p = .025, η = 0.120). Post-hoc comparisons with Bonferroni correction indicated that for adolescents with NSSI disorder who received G-CBT treatment, the suppression was significantly lower than for the controls ( p = .003; see Fig. 2 b. B). 3.4.3. Eye movement in emotional areas of interest 3.4.3.1. Fixation count The ANOVA of the fixation counts (see Table 2 , Fig. 3 a. A) revealed that the group × time × task type interaction was significant ( F (2, 78) = 3.276, p = .047, η = 0.077, Greenhouse-Geisser corrected). After the intervention, the results of group × task type repeated-measures ANOVA showed a significant interaction ( F (2, 78) = 3.926, p = .027, η = 0.091, Greenhouse-Geisser corrected). Post-hoc comparisons with Bonferroni correction showed that after eight sessions of G-CBT, adolescents with NSSI disorder had more fixation counts for unpleasant images than the controls under reappraisal conditions ( p = .001). For the distraction condition, there was no significant difference in fixation counts between the two groups after G-CBT ( p = .166). Table 2 Eye-tracking indices (Emotional Areas of Interest, e-AOI) on the fixation time (FT) and fixation count (FC) for G-CBT and control conditions T1 M(SD) T2 M(SD) View negative Reappraisal Distraction View negative Reappraisal Distraction G-CBT (n = 21) # FT (ms) 847.176 (657.496) 618.825 (499.619) 563.311 (498.570) 1004.851 (551.360) 901.916 *** (352.021) 613.240 (370.902) FC 2.976 (1.959) 2.179 (1.469) 2.054 (1.592) 4.066 (1.388) 3.509 *** (1.173) 2.428 (1.143) Control (n = 20) FT (ms) 786.027 (602.415) 552.076 (379.026) 463.988 (375.887) 740.646 (514.964) 466.136 (374.255) 459.911 (488.325) FC 3.262 (1.958) 2.363 (1.336) 2.041 (1.227) 3.229 (1.808) 2.033 (1.371) 1.870 (1.382) Note: T1: Pretreatment; T2: Posttreatment; M: mean; SD: Standard deviation; ms: millisecond. # One missing data was observed for the G-CBT condition. ***p < 0.001. 3.4.3.2. Fixation time Repeated-measures ANOVA on the fixation time (see Table 2 , Fig. 3 a. B) displayed a marginally significant three-factor interaction ( F (2, 78) = 2.556, p = .057, η = 0.061, Greenhouse-Geisser corrected). After the treatment, a 2 × 3 repeated-measures ANOVA was conducted. The results illustrated the main effect of both group ( F (2, 78) = 4.956, p = .032, η = 0.110) and task type ( F (2, 78) = 27.799, p < .001, η = 0.416, Greenhouse-Geisser corrected). There was a significant interaction for group × task type ( F (2, 78) = 4.957, p = .012, η = 0.113, Greenhouse-Geisser corrected). Bonferroni-corrected post hoc analyses or Post-hoc comparisons with Bonferroni correction revealed that the G-CBT group had longer fixation duration for negative images than the controls under reappraisal conditions ( p < .001). Under the distraction condition, after the intervention, the group difference was insignificant on fixation duration ( p = .239). These findings suggest that G-CBT may be associated with improved emotion regulation, especially reappraisal. 3.4.3.3. Temporal-course analysis We performed a temporal-course analysis to reveal the process of fixation duration on negative images and how this changed over time (see Fig. 3 b). A 2 × 3 × 8 repeated-measures ANOVA showed a marginally significant group × task type interaction ( F (2, 76) = 2.890, p = .063, η = 0.071, Greenhouse-Geisser corrected). Subsequent post hoc comparisons with Bonferroni correction indicated that the G-CBT group spent more time on unpleasant images than the controls under reappraisal conditions ( p = .004). We next conducted an independent-sample t-test. For reappraisal conditions, a significant increase occurred in stages between 0 ms and 1500 ms as well as between 2000 ms and 4000 ms. 3.4.4. Improvements in clinical symptoms 3.4.4.1. Depression Repeated-measures ANOVA was conducted on HAMD (see Fig. 2 b, C). There was a main effect of time ( F (1, 40) = 4.772, p = .035, η = 0.107) and a significant group × time interaction ( F (1, 40) = 6.567, p = .014, η = 0.141). Bonferroni-corrected post hoc analyses showed that the G-CBT led to significantly reduced depression symptoms in adolescents with NSSI disorder when compared with the controls ( p = .002). 3.4.4.2. Alexithymia The ANOVA on the efficacy of G-CBT in improving alexithymia displayed a significant interaction between group and time ( F (1, 40) = 12.267, p = .001, η = 0.235). After the intervention, the G-CBT resulted in significantly reduced alexithymia in adolescents with NSSI disorder compared with the controls ( p = .001). 3.4.4.3. Associations between alexithymia components and changes in NSSI behaviors Correlation analyses controlling for baseline depression were administered to investigate whether alexithymia components were related to improvement in NSSI behaviors (see Table 3 a). The results showed that difficulty identifying feelings (F1) and difficulty describing feelings (F2) were not significantly related to the improvement of NSSI behaviors after G-CBT. However, the level of EOT (externally oriented thinking, F3) before the intervention was negatively related to two indicators of NSSI (posttreatment minus pretreatment). Linear regression analyses controlling for baseline depression indicated that EOT significantly predicted changes in total and tissue damage behaviors, but did not significantly predict changes in non-tissue damage behaviors ( β = -0.356, p = .088; see Table 3 b). Table 3 a Partial correlations between the variables of interest 1.TAS-20 (Total) 1 2 3 4 5 6 7 — 2.TAS-20 (F1) .690*** — 3.TAS-20 (F2) .695*** .155 — 4.TAS-20 (F3) .354 − .182 .101 — 5.Total (-) − .276 − .131 .037 − .491* — 6.Tissue damage (-) − .333 − .201 .042 − .519* .894*** — 7.No tissue damage (-) − .171 − .041 .026 − .372 .909*** .626** — Note: Values are partial correlation coefficients controlling for baseline depression (HAMD scores); F1: Difficulty identifying feelings; F2: Difficulty describing feelings; F3: Externally oriented thinking; (-): Pretreatment minus posttreatment; *p < 0.05, **p < 0.01,, ***p < 0.001. Table 3 b Results from prediction analyses Baseline measure Outcome Coefficients Model Summary Beta t p R 2 F p TAS-20 (F3) Total (-) − .493 -2.521* .020 .309 4.480* .025 Tissue damage (-) − .544 -2.715* .013 .276 3.806* .040 Non-tissue damage (-) − .356 -1.794 .088 .289 4.062* .033 Note: Baseline depression (HAMD scores) was controlled for in all analyses; F3: Externally oriented thinking; (-): Pretreatment minus posttreatment; *p < 0.05. 4. Discussion We have demonstrated that G-CBT may improve emotion regulation and reduce NSSI behaviors in adolescents with NSSI disorder. Using an eye-tracking approach, we identified that eight sessions of G-CBT may have contributed to enhanced emotion regulation, mainly manifested as improving emotional ratings for negative images and increasing gaze (i.e., fixation count, fixation time) toward these pictures under reappraisal conditions. According to the temporal-course analysis, after the G-CBT, the fixation time on unpleasant images was significantly increased under reappraisal conditions, which occurred at almost all phases (from 0-1500 ms and 2000–4000 ms). In addition, compared with the control condition, participants receiving G-CBT showed improvements in depression and alexithymia, along with reductions in NSSI frequency. It was noteworthy that higher levels of EOT predicted poorer improvement in NSSI outcomes. However, these effects should be interpreted with caution. As participants in both groups received usual medication, and non-specific factors such as expectancy or placebo effects cannot be ruled out, the observed changes cannot be attributed solely to the G-CBT intervention. Notably, the effects of G-CBT were not uniform across different emotion regulation strategies. Contrary to our hypothesis, G-CBT did not significantly improve distraction-based emotion regulation. This may be because the intervention primarily targeted cognitive reappraisal rather than distraction, thus did not directly train distraction. Moreover, meta-analytic evidence suggests that attentional deployment strategies, including distraction, show heterogeneous and sometimes negligible effects on emotional outcomes (Webb et al., 2012 ), likely due to variability across subtypes. In addition, improvements in reappraisal may not readily transfer to other strategies, which rely on distinct regulatory processes. Our results support Gross's process model of emotion regulation. Aligned with the process model (Gross, 2015 ), emotion regulation deficits are related to maladaptive performance, whereas the heightened ability to regulate emotion encourages more comfortable moods and adaptive actions (Sheppes, Suri, & Gross, 2015 ). In this study, we found an increased gaze time for negative pictures under reappraisal conditions in the G-CBT group compared with the controls. We observed effects on fixation duration during the reappraisal process, indicating the stages of attention deployment and cognitive change, which was in agreement with previous researches (Bebko, Franconeri, Ochsner, & Chiao, 2011 ; Dolcos et al., 2020 ). A potential explanation was that the acquisition of enhanced attentional employment after the training dampened the subjective emotional experiences (Dolcos et al., 2020 ), in turn, resulted in greater success in reappraisal and subsequently led to decreased negative emotions (Sanchez, Everaert, & Koster, 2016 ). Another possible reason was that reappraisal was associated with a distinct pattern of attention deployment compared to distraction, as individuals engaging in cognitive reappraisal exhibited longer gaze time within the e-AOIs (Bartolomeo, Culbreth, Ossenfort, & Strauss, 2020 ). The aforementioned pattern implies that effective reappraisal entails attentional employment toward stimulating content in order to generate an alternative interpretation of the image. Furthermore, neuroimaging provides evidence for the efficacy of G-CBT in developing reappraisal. Prior studies indicated that twelve sessions once weekly of CBT treatment resulted in decreased amygdala reactivity during emotion perception and experience (Gorka et al., 2019 ) and increased activation in reappraisal-related brain regions (e.g., dorsolateral prefrontal cortex, dlPFC) (Goldin et al., 2021 ). In line with this, we found that individuals’ emotional ratings for unpleasant images were elevated under reappraisal conditions after the intervention. Collectively, adolescents who received CBT treatment can be more flexible in controlling their emotional response using reappraisal. The improvement of emotional regulation allows them to cope with distress and replace self-harm behavior with adaptive activities. Additionally, the temporal-course analysis revealed that, after intervention, the gaze time of adolescents with NSSI disorder was improved at almost all phases of reappraisal (between 0 and 1500 ms and between 2000 and 4000 ms). This suggested that the G-CBT group spent more time on unpleasant images from the start of executing the reappraisal strategies, and the improvement was sustained. Although recent research has indicated that reappraisals still effectively regulate negative emotions after controlling the fixation time (Manera, Samson, Pehrs, Lee, & Gross, 2014 ), individuals who shift their eyes from undesired areas tended to show a smaller decrease in negative ratings for unpleasant images (Robinson, Sheen, Sliwinski, Mu, & Compton, 2021 ). Therefore, it is important to take fixation duration into account when examining the effects of G-CBT on reappraisal in adolescents with NSSI disorder. Regarding the clinical symptoms, our results documented that the improvements were significant after the intervention. Note that depression often co-occurs with NSSI during the adolescent period (Tilton-Weaver, Marshall, & Svensson, 2019 ). In our present study, adolescents with NSSI disorder reported greater reductions in depression symptoms after the G-CBT, consistent with previous studies (Kaess et al., 2020 ; Slee, Spinhoven, Garnefski, & Arensman, 2008 ). Synthetic evidence (LeMoult & Gotlib, 2019 ) indicated that cognitive control biases were a trait of depressed individuals, which led to difficulties in cognitive emotion regulation (e.g., reduced frequency of reappraisal). CBT involves reconstructing dysfunctional cognition to improve emotional regulation, which alleviates depressive symptoms. For example, a recent study found that 10 sessions of CBT resulted in depressed individuals being more fixated on happy faces, which is the opposite of unpleasant face images. In addition, improvement in cognitive control was associated with decreased depressive symptoms (Vazquez et al., 2018 ). Taken together, these findings showed that G-CBT contributed to improving emotional regulation for adolescents with NSSI disorder, thereby reducing their depression. After the intervention, we observed alleviations in NSSI behaviors among adolescents, especially with a significant reduction in tissue damage behaviors. Tissue damage (e.g., cutting and carving the body) is the most common form of self-injury (Nock, 2010 ). Intense physical pain (or bleeding) may have great significance for the relief of negative emotions (Naoum et al., 2016 ) and for up-regulating positive emotions (Stacy, Pepper, Clapp, & Reyna, 2022 ). It has been argued that self-harm represents an experience avoidance strategy that prevents adaptive cognitive processing of stimuli that cause strong negative emotions (Chapman, Gratz, & Brown, 2006 ). Our results suggested that eight sessions of G-CBT decreased the frequency of avoidant strategies and prompted adolescents to use adaptive emotion regulation strategies (i.e., reappraisal) to participate actively in the cognitive processing of unpleasant stimuli. Adaptive emotion regulation strategies reduce the intensity of negative stimuli, allowing the individual to manage negative emotions and further reduce NSSI frequency. Nevertheless, improvement in the frequency of non-tissue injury in the G-CBT group was not significant, mainly due to the small sample size. Another possibility was that, as well as fewer comorbid mental illnesses, individuals with non-tissue injury had less frequent and severe NSSI behaviors, but were susceptible to environmental factors (Whitlock, Muehlenkamp, & Eckenrode, 2008 ). These findings suggested that we need to focus on the long-term effects of the G-CBT intervention to prevent recurrence. Interestingly, our results indicated that alexithymia, especially EOT, affected adolescent NSSI behaviors. EOT refers to people with utilitarian and pragmatic thinking that leads individuals to prefer to make efforts to avoid unpleasant stimuli (Schroeders, Kubera, & Gnambs, 2022 ). Adolescents with NSSI disorder usually show high EOT (Gatta, Dal Santo, Rago, Spoto, & Battistella, 2016 ), which is a particular risk factor for suicide (Ghorbani, Khosravani, Sharifi Bastan, & Jamaati Ardakani, 2017). Likewise, we found that baseline EOT showed a negative correlation with reduced NSSI actions and predicted a smaller improvement after the G-CBT. Higher EOT resulted in adolescents with NSSI disorder obtaining limited gains from G-CBT intervention. Specifically, a high level of EOT may lead to individuals who have not had the opportunity to learn adaptive strategies to handle future challenging events (Davydov, Stewart, Ritchie, & Chaudieu, 2010 ). From a clinical perspective, the present findings suggest that CBT may improve emotion regulation skills, and diminish depressive symptoms and NSSI behaviors. This reinforces the clinical insights that CBT can modify both emotional regulation and clinical symptoms. Importantly, the EOT dimension of alexithymia was associated with poorer improvement in NSSI, indicating that it may represent a modifiable therapeutic target. This interpretation is supported by prior research showing that alexithymic individuals have significant deficiencies in a particular type of mental state understanding associated with emotional awareness, which greatly limits their ability to grow or change (Demers et al., 2019 ). Encouragingly, tailored short-term interventions have been shown to reduce alexithymia (Cameron, Ogrodniczuk, & Hadjipavlou, 2014 ). Taken together, incorporating components that enhance emotional awareness and reduce alexithymia (especially EOT) may further improve the effectiveness of G-CBT in this population. The present study integrates eye-tracking methodology within a randomized controlled design to provide an objective, process-level index of attentional deployment during emotion regulation, while prior CBT studies have largely relied on self-report measures or clinician-rated scales to evaluate changes in emotion regulation. By examining gaze patterns toward emotional stimuli under different regulation conditions, this study provides a more fine-grained understanding of the cognitive mechanisms that may underlie therapeutic change. Despite these strengths, several potential limitations should be mentioned in this study. First, the sample size was relatively small, which may have limited statistical power. Second, the absence of follow-up assessments precludes conclusions about the long-term sustainability of the intervention effects. Third, participants were recruited from two urban hospital settings, which may limit representativeness and introduce potential demographic biases (e.g., urban vs. rural populations, socioeconomic status), thereby constraining external validity. Future research should aim to replicate these findings in larger, multi-site randomized controlled trials with more diverse samples to enhance generalizability. Moreover, longitudinal follow-up assessments are also needed to determine the durability of treatment effects. In addition, integrating neuroimaging techniques (e.g., fMRI) could help elucidate the neural mechanisms underlying changes in emotion regulation. Finally, ecological momentary assessment may provide a valuable approach to capturing real-time emotion regulation processes and their dynamic relationship with NSSI behaviors in daily life. 5. Conclusion In summary, the results of the current study suggested that G-CBT may be an effective treatment for improving emotion regulation strategies and reducing self-injurious actions in adolescents with NSSI disorder. Certain aspects of alexithymia (i.e., EOT) specifically predicted a reduction in tissue damage. These findings have potential implications for the treatment of adolescents with NSSI disorder. Declarations Funding statement This research was supported by the National Natural Science Foundation of [COUNTRY] (Grant Nos. [XXX, XXX, XXX]), the Ministry of Education Humanities and Social Science Project (Grant No. [XXX]), the Applied Medical Scientific Research Project of [LOCAL HEALTH COMMISSION] (Grant No. [XXX]), and the Clinical Science Foundation of [HOSPITAL NAME] (Grant No. [XXX]). Ethical Approvals and Statements This study was approved by the Ethics Committee of Anhui Medical University (81220128). All participants provided informed consent; for participants under the age of 18, written informed consent was obtained from their legal guardians in addition to their own assent. Declaration of competing interest The authors report no conflict of interest. Acknowledgements The authors thank all the study participants for their contributions. Author Contribution Zixuan Guo: Formal analysis, Writing-original draft. Jun Liu: Data curation, Formal analysis. Qiuyu Chen: Investigation. Li Zhu: Resources. Sisi Xie: Resources. Chunyan Zhu: Resources. Fengqiong Yu: Resources. 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Supplementary Files SupplementaryMaterials.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 18 May, 2026 Reviews received at journal 12 May, 2026 Reviewers agreed at journal 23 Apr, 2026 Reviewers agreed at journal 22 Apr, 2026 Reviewers agreed at journal 21 Apr, 2026 Reviewers invited by journal 21 Apr, 2026 Editor assigned by journal 16 Apr, 2026 Submission checks completed at journal 16 Apr, 2026 First submitted to journal 12 Apr, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9392047","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":629835864,"identity":"e5ee46c1-6cb9-4561-943d-2fa3aadb096a","order_by":0,"name":"Zixuan Guo","email":"","orcid":"","institution":"Anhui Medical University","correspondingAuthor":false,"prefix":"","firstName":"Zixuan","middleName":"","lastName":"Guo","suffix":""},{"id":629835865,"identity":"49466397-cb67-4692-b7be-16644ddfed38","order_by":1,"name":"Jun Liu","email":"","orcid":"","institution":"Anhui Medical University","correspondingAuthor":false,"prefix":"","firstName":"Jun","middleName":"","lastName":"Liu","suffix":""},{"id":629835866,"identity":"17388383-d25f-47ef-8dad-002bd88471df","order_by":2,"name":"Qiuyu Chen","email":"","orcid":"","institution":"Anhui Medical University","correspondingAuthor":false,"prefix":"","firstName":"Qiuyu","middleName":"","lastName":"Chen","suffix":""},{"id":629835868,"identity":"3c47dc0d-cfbf-488b-8c2a-4013d19c2f36","order_by":3,"name":"Li Zhu","email":"","orcid":"","institution":"Anhui Mental Health Center","correspondingAuthor":false,"prefix":"","firstName":"Li","middleName":"","lastName":"Zhu","suffix":""},{"id":629835872,"identity":"3ccc0cb5-55c8-4cec-a854-ac629c0e4faa","order_by":4,"name":"Sisi Xie","email":"","orcid":"","institution":"Anhui Medical University","correspondingAuthor":false,"prefix":"","firstName":"Sisi","middleName":"","lastName":"Xie","suffix":""},{"id":629835873,"identity":"1fca68e6-c37d-4082-98b1-83595f8585e4","order_by":5,"name":"Chunyan Zhu","email":"","orcid":"","institution":"Anhui Medical University","correspondingAuthor":false,"prefix":"","firstName":"Chunyan","middleName":"","lastName":"Zhu","suffix":""},{"id":629835874,"identity":"4555ae44-0686-43f6-8e36-e9e34fd501ca","order_by":6,"name":"Fengqiong Yu","email":"","orcid":"","institution":"Anhui Medical University","correspondingAuthor":false,"prefix":"","firstName":"Fengqiong","middleName":"","lastName":"Yu","suffix":""},{"id":629835876,"identity":"6b949782-80e7-419e-a91d-205c603f5973","order_by":7,"name":"Gong-Jun Ji","email":"","orcid":"","institution":"Anhui Medical University","correspondingAuthor":false,"prefix":"","firstName":"Gong-Jun","middleName":"","lastName":"Ji","suffix":""},{"id":629835881,"identity":"987fceb9-c437-45a2-8b04-693bafb2a431","order_by":8,"name":"Kai Wang","email":"","orcid":"","institution":"The First Affiliated Hospital of Anhui Medical University","correspondingAuthor":false,"prefix":"","firstName":"Kai","middleName":"","lastName":"Wang","suffix":""},{"id":629835885,"identity":"0bb7566f-5904-4436-9f02-ac26f01863c7","order_by":9,"name":"Lei Zhang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA90lEQVRIiWNgGAWjYBACfmbG5sc/DCR47OcfPsAMEUvAr0WyvfmYMUOFjZyBBFsCcVoMzhxLkGY4k2YMtMiAOC0MN3IMjAvbDidul+75+Lkw5zADP3uOAcPPHbh1MM7IMXg8E6hl55yzm6VnbjvMINnzxoCx9wxuLcwSOQYGvEAtDQdyN0jzArUYAO1lZmzDrYUNqEUCoiXn8W+QFntCWnh4gN7nAXn/Rg4bxBYJAlok2JuPGc4ABrJkzzEza95t6TwSZ54VHOzFo8X+MGPzgw/AEOZnb358m3ebtRx/e/LGBz/xaMF0KYg4QIKGUTAKRsEoGAVYAADzNFWZ9hcuhAAAAABJRU5ErkJggg==","orcid":"","institution":"Anhui Medical University","correspondingAuthor":true,"prefix":"","firstName":"Lei","middleName":"","lastName":"Zhang","suffix":""}],"badges":[],"createdAt":"2026-04-12 06:24:02","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9392047/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9392047/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":108398050,"identity":"4bea24f4-3557-4b54-aba6-cfdb55ea1b14","added_by":"auto","created_at":"2026-05-04 08:26:03","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":126968,"visible":true,"origin":"","legend":"\u003cp\u003eFlowchart of study participants. G-CBT: Group Cognitive Behavioral Therapy.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-9392047/v1/c4876224cbab8f6a1e817bbd.png"},{"id":108398146,"identity":"435a452c-cbee-4509-af1e-e5698c9f679e","added_by":"auto","created_at":"2026-05-04 08:26:18","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":56945,"visible":true,"origin":"","legend":"\u003cp\u003ea. A: Changes in total NSSI at posttreatment; B: Changes in tissue damage at posttreatment; C: Changes in no tissue damage at posttreatment.\u003c/p\u003e\n\u003cp\u003e*p \u0026lt; 0.05.\u003c/p\u003e\n\u003cp\u003eb. A: Changes in reappraisal from pretreatment to posttreatment; B: Changes in suppression from pretreatment to posttreatment; C: Changes in depression symptoms from pretreatment to posttreatment.\u003c/p\u003e\n\u003cp\u003e**p \u0026lt; 0.01.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-9392047/v1/065f9166c8a031d39c381556.png"},{"id":108398062,"identity":"ea072908-5072-48f1-abaf-06e918079e35","added_by":"auto","created_at":"2026-05-04 08:26:07","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":119724,"visible":true,"origin":"","legend":"\u003cp\u003ea.\u003cstrong\u003e \u003c/strong\u003eA: The fixation counts for each instruction was compared between the G-CBT group and the control group at posttreatment; B: The fixation time for each instruction was compared between the G-CBT group and the control group at posttreatment.\u003c/p\u003e\n\u003cp\u003e***p \u0026lt; 0.001.\u003c/p\u003e\n\u003cp\u003eb.\u003cstrong\u003e \u003c/strong\u003eTemporal-course charts of the fixation time in the e-AOI between the G-CBT group and the control group after intervention. Gray shade indicates the set of time epochs when the group differences are significant.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-9392047/v1/2fdde8ed20617621d416b260.png"},{"id":108398179,"identity":"ab619e46-8ede-4075-9d44-a99b41ad10a0","added_by":"auto","created_at":"2026-05-04 08:26:29","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":794772,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9392047/v1/c808fcfb-7efe-4d92-b86f-ea96a50795d7.pdf"},{"id":108398112,"identity":"2ebafd1c-b991-493c-9b08-76747b9e8cf4","added_by":"auto","created_at":"2026-05-04 08:26:12","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":23204,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryMaterials.docx","url":"https://assets-eu.researchsquare.com/files/rs-9392047/v1/19b98fe20bcc5f7027d25e1d.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"The efficacy of cognitive behavioral therapy (CBT) in improving emotion regulation and self-injurious behavior in adolescents with non-suicidal self-injury (NSSI)","fulltext":[{"header":"Highlights","content":"\u003cul start=\"50\"\u003e\n \u003cli\u003eG-CBT may be effective in reducing NSSI behaviors and improving emotion regulation.\u003c/li\u003e\n \u003cli\u003eThe improvement of reappraisal processes is continuous after G-CBT.\u003c/li\u003e\n \u003cli\u003eA higher level of EOT predicts poorer improvement in NSSI behaviors after intervention.\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"1. Introduction","content":"\u003cp\u003eNon-suicidal self-injury (NSSI) is the direct and deliberate destruction of body tissue without the intent to die (Nock, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e2010\u003c/span\u003e). Worldwide, the aggregate estimate of the 12-month prevalence of NSSI is 19.5% (Lim et al., \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). Adolescence is a vulnerable period for developing NSSI (Muehlenkamp, Xhunga, \u0026amp; Brausch, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). The typical onset of NSSI occurs at age 12 (Cipriano, Cella, \u0026amp; Cotrufo, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2017\u003c/span\u003e) and it peaks at between 15-and 17-years-old (Plener, Schumacher, Munz, \u0026amp; Groschwitz, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). Converging results show that NSSI is a high risk factor for later suicide attempts (Griep \u0026amp; MacKinnon, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2020\u003c/span\u003e) and behaviors (Whitlock et al., \u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e2013\u003c/span\u003e). Past studies have illustrated that NSSI was strongly associated with emotion dysregulation. Specifically, greater emotion regulation deficits are related to higher rates of NSSI (Wolff et al., \u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). Although NSSI provides relief from negative affect (Klonsky, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2009\u003c/span\u003e), deterioration of emotions follows (Koenig et al., \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Therefore, considering the potential risks and short-term benefits of NSSI, developing the ability to regulate emotions is of great significance for alleviating NSSI in adolescents.\u003c/p\u003e \u003cp\u003eEmotion regulation, whether up- or down-regulation, aims to influence our or others\u0026rsquo; current emotional states (Gross, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2002\u003c/span\u003e). Emotion regulation strategy is a vast family tree that includes cognitive reappraisal, distraction, and expressive suppression (McRae \u0026amp; Gross, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). According to Gross\u0026rsquo;s process model, emotion regulation involves multiple-stage processes: an event or stimulus, distribution of attention, assessing the event through appraisal, and responding to the event (Gross, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e1998\u003c/span\u003e). Experiencing failure in a certain phase of the model, such as attentional bias to stimuli, suppressing emotions, or failing to use effective reappraisal, can result in the failure or dysregulation of emotion regulation, which ultimately leads to the development of maladaptive coping strategies such as NSSI (Gross, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). Among adolescents with NSSI disorder, relieving negative emotions is the primary purpose of engaging in NSSI (P. J. Taylor et al., \u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). NSSI is therefore conceptualized as a maladaptive emotion regulation strategy (Nock, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e2010\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAmong emotion regulation strategies, cognitive reappraisal is typically associated with positive consequences (Kivity \u0026amp; Huppert, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; McRae \u0026amp; Gross, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). However, adolescents who engage in NSSI are poor at using reappraisal to regulate negative emotions (Wolff et al., \u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). Compared to non-NSSI adolescents, adolescents with NSSI disorder reported using less active reappraisal (Hauber, Boon, \u0026amp; Vermeiren, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2019\u003c/span\u003e), and this related to a higher NSSI risk within twelve months (Voon, Hasking, \u0026amp; Martin, \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e2014\u003c/span\u003e). In addition, adolescents with NSSI disorder usually experience uncontrolled negative emotions (Kranzler et al., \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2018\u003c/span\u003e), and it is harder to use reappraisal effectively in highly intensive situations (Kranzler et al., \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Raio, Orederu, Palazzolo, Shurick, \u0026amp; Phelps, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e2013\u003c/span\u003e). Surprisingly, another frequently-used emotion regulation strategy, distraction, failed to prevent adolescents from engaging in NSSI behaviors (Koenig et al., \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Improving the ability to modify emotion is therefore an important therapeutic intervention target in NSSI disorder clinic practice (Gratz, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2007\u003c/span\u003e). Of note, attention is fundamental to both cognitive reappraisal and distraction. According to the modal model of emotion, regulating emotional responses involves both attentional focusing (concentration) and shifting (distraction). Crucially, because emotional responses evolve and stimuli can be highly provocative, effective reappraisal demands sustained attention and effort (Chung, Heakes, \u0026amp; Kaufman, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Kalisch, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2009\u003c/span\u003e; Kalisch et al., \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2011\u003c/span\u003e; Wang, Li, Li, \u0026amp; Chen, \u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e2024\u003c/span\u003e)(page R2 2First). Therefore, cognitive reappraisal requires more attentional resources, specifically an increase in gaze time to emotional stimulus throughout the entire reappraisal process.\u003c/p\u003e \u003cp\u003eCBT is listed as the first-line treatment for adolescent depression and anxiety disorders (Rith-Najarian et al., \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e2019\u003c/span\u003e), and convincing evidence supports its positive role in improving emotion regulation skills (Daros et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). It is important to note that CBT is also an efficient therapeutic approach for adolescents with NSSI disorder (Iyengar et al., \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). Several manualized and specially developed CBT studies involve cultivating adaptive emotion regulation skills that need to be highlighted (Edinger et al., \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Fischer, Brunner, Parzer, Resch, \u0026amp; Kaess, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2013\u003c/span\u003e; Hogberg \u0026amp; Hallstrom, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Kaess et al., \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). A flexible manual CBT intervention (8\u0026ndash;12 intervention sessions) showed a greater decrease in the frequency of NSSI and depression among adolescents in the CBT group after the treatment (Fischer et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2013\u003c/span\u003e). Notably, another study demonstrated that CBT led to significantly reduced depressive symptoms and altered attentional biases which was strongly associated with maintenance of gaze (Vazquez et al., \u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). However, mixed results were exhibited for the subsequent two manualized CBT interventions for adolescents with NSSI disorder (Edinger et al., \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Kaess et al., \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). One possible explanation is that, for adolescents who engage in NSSI, more efforts may need to be focused on emotion regulation(Gratz, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2007\u003c/span\u003e; Sahlin et al., \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e2017\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eEye-tracking methodology is commonly used to analyze the typical gaze pattern of individuals with affective disorders (Armstrong \u0026amp; Olatunji, \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2012\u003c/span\u003e). As a general rule, the eye movements reflect the mental processing course of cognitive and emotional states, regardless of what we are looking at in any given time (Carter \u0026amp; Luke, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Fixation time and fixation count are frequently used eye-tracking indicators, representing the attentional allocation changes of different stages in information processing (Skaramagkas et al., \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). It is worth noting that the advantage of eye-tracking in temporal sensitivity provides a moment-by-moment insight into potential cognition instead of just showing final results (Carter \u0026amp; Luke, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). A recent eye-tracking study found that CBT treatment encouraged depressed individuals to spend more time watching positive face images (Vazquez et al., \u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). After sixteen sessions of CBT, the difference between children with separation anxiety disorder and non-anxious children no longer existed in the post-assessment using eye tracking, indicating the efficacy of the CBT treatment (In-Albon, Ruf, \u0026amp; Schmid, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). To date, there are few studies on changes in eye gaze towards emotional stimuli during emotion regulation following CBT intervention in adolescents with NSSI disorder.\u003c/p\u003e \u003cp\u003eThe present study aimed to evaluate the efficacy of G-CBT in adolescents with NSSI disorder. First, we hypothesized that, compared with the control condition (medication only), adolescents receiving G-CBT would show a greater reduction in NSSI behaviors at post-intervention (primary outcome). Second, we hypothesized that G-CBT would lead to improvements in emotion regulation (secondary outcomes), as reflected in both self-report measures (Emotion Regulation Questionnaire, ERQ) and eye-tracking indices under reappraisal and distraction conditions. Specifically, participants in the G-CBT group were expected to exhibit longer gaze duration toward negative stimuli during reappraisal. Furthermore, we expected that depressive symptoms, anxiety symptoms, and alexithymia would decrease following the intervention. Finally, we explored whether baseline alexithymia would predict treatment outcomes.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cp\u003eWe conducted a parallel-group randomised controlled trial (RCT) with pre- and post-intervention assessments. Participants were assessed at baseline prior to the intervention and again immediately after completion of the 4-week intervention. Figure\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e shows the study design and summarizes participant flow.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1. Participants\u003c/h2\u003e \u003cp\u003eA priori power analyses was performed with G*Power (v.3.1.9.7). For a within-between interaction effect in a repeated-measures ANOVA (2 groups \u0026times; 2 time points), assuming a medium effect size (Cohen\u0026rsquo;s f\u0026thinsp;=\u0026thinsp;0.25), an alpha of 0.05 (two-sided), and a power of 0.80, the analysis indicated that a total sample size of 34 participants (17 per group) was necessary. Considering an anticipated attrition rate of approximately 30%, a total of 54 participants were recruited to ensure adequate statistical power.\u003c/p\u003e \u003cp\u003eA total of 72 adolescents were screened, of whom 54 met the eligibility criteria and consented to participate. Participants were recruited from the First Affiliated Hospital of Anhui Medical University and the Anhui Mental Health Center from February to November 2022. Inclusion criteria were: (1) age 12\u0026ndash;18 years; (2) diagnosis of NSSI disorder based on the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition) and NSSI in the past two weeks; and (3) reported normal or corrected vision through glasses or contact lenses. Participants were not included if they had: (1) attempted suicide or current suicide plans; (2) acute psychotic symptoms; (3) impaired cognitive function; (4) received extra psychotherapeutic intervention; and (5) inability to understand and interact in Chinese.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2. Randomization and Masking\u003c/h2\u003e \u003cp\u003eParticipants were randomly assigned in a 1:1 ratio to either the G-CBT group or the control group. Randomization was conducted by an independent researcher not involved in recruitment, assessment, or intervention delivery, using a computer-generated random sequence. Participants were blinded to group assignment, while therapist, due to the nature of the psychological intervention, were not. However, outcome assessors were blinded to group allocation to minimize assessment bias.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3. Intervention\u003c/h2\u003e \u003cp\u003eAll participants continued their regular medication during the study period. Each individual took 50\u0026ndash;150 mg of sertraline (50 mg per tablet) daily. Moreover, 12 individuals took 50 mg of quetiapine (25 mg per tablet).\u003c/p\u003e \u003cp\u003e \u003cb\u003eG-CBT Group\u003c/b\u003e \u003c/p\u003e \u003cp\u003eIn addition to their usual medication, participants in the G-CBT condition received eight sessions that were developed to reduce NSSI. The protocol integrated the literature with the proposals of several professionals in CBT. The content of the intervention for adolescents with NSSI disorder targets emotion regulation. The therapist received 3 days of training on treatment protocols and participated in weekly supervised meetings that were chaired by expert licensed psychologists. To maintain the integrity of treatment, the therapist followed a standardized protocol. All intervention sessions were audio-recorded, and a random subset of recordings was independently reviewed by licensed clinical psychologists using a manual-based adherence checklist to evaluate consistency with the protocol. For details about the protocol, see the Supplementary Materials.\u003c/p\u003e \u003cp\u003e \u003cb\u003eControl Group\u003c/b\u003e \u003c/p\u003e \u003cp\u003eParticipants in the control group received usual medication, which consisted of regular medication management, routine clinical monitoring, and psychoeducation, but did not receive any structured psychotherapy or behavioral interventions targeting NSSI and emotion regulation during the study period.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.4. Measures\u003c/h2\u003e \u003cdiv id=\"Sec7\" class=\"Section3\"\u003e \u003ch2\u003e2.4.1. Primary outcome measure\u003c/h2\u003e \u003cp\u003eThe primary outcome of this study was the change in NSSI behaviors, assessed using the Adolescent Non-suicidal Self-injury Assessment Questionnaire (ANSAQ). The ANSAQ (Yuhui., Wan., Jiahu., \u0026amp; Fangbiao., 2018) was developed based on the Functional Assessment of Self-Mutilation. This scale consists of 31 items, comprising behavioral subscales (12 items) and functional subscales (19 items). The behavioral subscales are divided into two dimensions (a) tissue damage (e.g., Deliberately cutting yourself) and (b) no tissue damage (e.g., Deliberately hitting a hard object with your head). The ANSAQ was administered to assess the frequency of NSSI behaviors during the preceding 2 weeks.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section3\"\u003e \u003ch2\u003e2.4.2. Secondary outcome measures\u003c/h2\u003e \u003cp\u003e \u003cb\u003eEmotion Regulation Questionnaire (ERQ)\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe ERQ, was developed by Gross et al. (Gross \u0026amp; John, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2003\u003c/span\u003e) to assess the habitual use of emotion regulation strategies. The two subscales are cognitive reappraisal (six items) and expressive suppression (four items). Items are presented on a seven-point Likert scale (1\u0026ndash;7) from strongly disagree to strongly agree. In the present study, the internal consistency of the ERQ was high, with Cronbach\u0026rsquo;s α values of 0.944 for the reappraisal subscale and 0.946 for the suppression subscale. The Cronbach\u0026rsquo;s α for the total scale was 0.801.\u003c/p\u003e \u003cp\u003e \u003cb\u003eEye-tracking measure\u003c/b\u003e \u003c/p\u003e \u003cp\u003eEye-tracking indices (e.g., fixation duration, fixation count) during emotion regulation tasks were collected to provide an objective measure of attentional deployment.\u003c/p\u003e \u003cp\u003e \u003cb\u003eHamilton Rating Scale for Depression (HAMD-17)\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe HAMD-17 (Hamilton, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e1960\u003c/span\u003e) was administered, to evaluate the severity of depressive symptoms on a five-point Likert scale (0\u0026ndash;4). Total scores ranged from 0 to 68. In the current sample, the scale demonstrated good internal consistency, with a Cronbach\u0026rsquo;s α of 0.920.\u003c/p\u003e \u003cp\u003e \u003cb\u003eHamilton Rating Scale for Anxiety (HAMA-14)\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe HAMA is a 14-item measure (Hamilton, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e1959\u003c/span\u003e) on a five-point Likert scale (0\u0026ndash;4). It addresses both psychological and somatic symptoms. The Cronbach\u0026rsquo;s α was 0.884 within the sample.\u003c/p\u003e \u003cp\u003e \u003cb\u003eChinese translation of the 20-item Toronto Alexithymia Scale (TAS-20-C)\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe TAS-20-C is a 20-item self-rated questionnaire used to assess alexithymia, including the three factors difficulty identifying feelings (F1), difficulty describing feelings (F2), and externally oriented thinking (F3). Each item is assessed on a five-point Likert scale (1\u0026ndash;5), and five items are scored in reverse. In general, total scores\u0026thinsp;\u0026ge;\u0026thinsp;61 represent high alexithymia, while scores\u0026thinsp;\u0026le;\u0026thinsp;51 indicate the absence of alexithymia (G. J. Taylor, Parker, Bagby, \u0026amp; Bourke, \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e1996\u003c/span\u003e). The scale has good reliability and validity in Chinese adolescents (Ling, Zeng, Yuan, \u0026amp; Zhong, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). In the current sample, Cronbach's alphas were 0.810 for F1, 0.804 for F2 and 0.702 for F3. The Cronbach\u0026rsquo;s α for the total scale was 0.818.\u003c/p\u003e \u003cp\u003eAll measures above were administered immediately before and after the intervention.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e2.5. Eye-tracking paradigm\u003c/h2\u003e \u003cp\u003eEye movements were recorded using a remote infrared eye-tracking system (iView X RED250; SensoMotoric Instruments, Germany) and analyzed with BeGaze software. The system sampled gaze data at 250 Hz. Stimuli were presented on a 22-inch monitor with a screen resolution of 1,920 \u0026times; 1,080 pixels. A standard five-point calibration procedure was conducted prior to the task, and calibration was accepted when the average error was \u0026lt;\u0026thinsp;1\u0026deg; of visual angle. Fixations were identified using the default BeGaze fixation detection algorithm based on a velocity-threshold identification method, with a minimum duration of 100 ms and a maximum dispersion of 1\u0026deg; of visual angle. For details on how to select visual materials and determine areas of interest, see see the Supplementary Materials.\u003c/p\u003e \u003cp\u003eRaw eye-tracking data were preprocessed before analysis. Periods of signal loss, blinks, and other artifacts were automatically detected and removed by the software. Trials with more than 20% missing samples were excluded, and only valid fixation data were included in the final analyses.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e2.6. Data analysis\u003c/h2\u003e \u003cp\u003eSPSS 22.0 was used for statistical analysis. We used chi-square and \u003cem\u003et\u003c/em\u003e-tests to compare the demographic characteristics of the two groups before G-CBT. To analyze the effects of G-CBT on eye movement of emotional areas of interest (e-AOI) before and after the intervention, we performed 2 \u0026times; 2 \u0026times; 3 repeated-measures ANOVA. When a significant interaction was observed, we conducted an independent-sample \u003cem\u003et\u003c/em\u003e-test to make a comparison. Additionally, we utilized a temporal-course analysis to explore the detailed changes in the eye gaze on negative images over time between the two groups. Based on previous eye-tracking studies examining emotional gaze processing (Zhao et al., \u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e2022\u003c/span\u003e), each 4-second image presentation was segmented into eight 500-millisecond segments. We employed a 2 \u0026times; 3 \u0026times; 8 repeated-measures ANOVA, with group (2: G-CBT and Controls) as a between-subject variable and task types (3: view negative, reappraisal, and distraction) and course (0-4000 ms) as within-subject variables.\u003c/p\u003e \u003cp\u003eMoreover, to examine the changes in valence and arousal, we employed 2 \u0026times; 4 repeated-measures ANOVA. A series of 2 \u0026times; 2 repeated-measures ANOVAs were used to examine the effects of G-CBT on ERQ, depression, anxiety, and NSSI frequency before and after the intervention. Correlation analyses were conducted to test the associations between variables of interest and NSSI behaviors. For multiple comparisons, Bonferroni corrections were applied to control for Type I error. Effect sizes were reported as partial η\u003csup\u003e2\u003c/sup\u003e (η) for all ANOVA analyses. When the assumption of sphericity was violated, Greenhouse\u0026ndash;Geisser corrections were applied. A two-tailed p value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant. Missing data were handled using listwise deletion. Participants with incomplete data on variables required for a given analysis were excluded from that analysis.\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003e3.1. Demographic characteristics\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e shows the demographic and clinical characteristics. All comparisons were insignificant.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic and clinic characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eG-CBT(n\u0026thinsp;=\u0026thinsp;22)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eControl(n\u0026thinsp;=\u0026thinsp;20)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003et\\\u003c/em\u003eχ\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM(SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15.41(1.563)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e15.45(2.114)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e-0.072\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.943\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(M/F)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7/15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5/15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.239\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.625\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM(SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.00(1.746)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e9.15(2.033)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e-0.257\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.798\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMoCA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM(SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28.14(2.678)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e27.55(2.064)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.789\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.435\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHAMD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM(SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25.50(5.466)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e24.40(5.072)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.674\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.504\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHAMA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM(SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24.27(5.650)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e22.10(5.721)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.237\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.223\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTAS-20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM(SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e67.45(5.449)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e64.50(8.727)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.329\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.191\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eERQ-R\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM(SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20.41(5.901)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e20.55(7.244)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e-0.069\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.945\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eERQ-S\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM(SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19.59(3.887)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e18.75(5.711)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.562\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.577\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003eNote: M: mean; SD, standard deviation; G-CBT, group cognitive-behavioral therapy; MoCA: Montreal cognitive assessment; HAMD, Hamilton Rating Scale for Depression; HAMA, Hamilton Anxiety Scale; TAS-20, Chinese translation of the 20-item Toronto Alexithymia Scale; ERQ, Emotion Regulation Questionnaire (R: cognitive reappraisal; S: expressive suppression).\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003e3.2. Treatment adherence and attrition\u003c/h2\u003e \u003cp\u003eIn the G-CBT group, two participants withdrew after attending three to four sessions due to perceived inefficacy, reporting that they did not perceive sufficient progress and had expected faster symptom relief. One additional participants discontinued due to poor attendance, primarily related to logistical barriers such as scheduling conflicts, or transportation difficulties; none reported dissatisfaction with the intervention content. Two further participants were excluded from the analysis at posttreatment assessment because they failed to provide eye-tracking data. In the control group, seven participants refused to complete the post-intervention assessment, with reasons including lack of direct incentive to complete follow-up measures (n\u0026thinsp;=\u0026thinsp;2), fatigue from the baseline assessment (n\u0026thinsp;=\u0026thinsp;2), and being unreachable despite multiple contact attempts (n\u0026thinsp;=\u0026thinsp;3). Attrition analyses comparing study completers to non-completers on age, gender, NSSI frequency, depressive symptoms, anxiety symptoms, alexithymia, and emotion regulation, revealed no significant group differences. The final analyzed sample consisted of 22 participants in the G-CBT group (7 males and 15 females, \u003cem\u003eM\u003c/em\u003e\u003csub\u003e\u003cem\u003eage\u003c/em\u003e\u003c/sub\u003e = 15.41, \u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1.563) and 20 participants in the control group (5 males and 15 females, \u003cem\u003eM\u003c/em\u003e\u003csub\u003e\u003cem\u003eage\u003c/em\u003e\u003c/sub\u003e = 15.45, \u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;2.114).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003e3.3. Primary outcome: Frequency of NSSI\u003c/h2\u003e \u003cp\u003eThere were insignificant group \u0026times; time interactions observed in total NSSI (\u003cem\u003eF\u003c/em\u003e(1, 40)\u0026thinsp;=\u0026thinsp;2.745, \u003cem\u003ep\u003c/em\u003e = .105, \u003cem\u003eη\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.064) and no tissue damage (\u003cem\u003eF\u003c/em\u003e(1, 40)\u0026thinsp;=\u0026thinsp;1.868, \u003cem\u003ep\u003c/em\u003e = .179, \u003cem\u003eη\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.045). The ANOVA for tissue damage displayed that the group (2: G-CBT and Control) \u0026times; time (2: pretreatment and posttreatment) interaction was marginally significant (\u003cem\u003eF\u003c/em\u003e(1, 40)\u0026thinsp;=\u0026thinsp;3.563, \u003cem\u003ep\u003c/em\u003e = .066, \u003cem\u003eη\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.082). A follow-up independent-simple t-test showed that the G-CBT group had decreased NSSI frequency in comparison with the controls (\u003cem\u003ep\u003c/em\u003e = .017) after the treatment (see Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e2\u003c/span\u003ea).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003e3.4. Secondary outcome\u003c/h2\u003e \u003cdiv id=\"Sec16\" class=\"Section3\"\u003e \u003ch2\u003e3.4.1. Valence and arousal\u003c/h2\u003e \u003cp\u003eRepeated-measures ANOVA (group \u0026times; task types) revealed a significant main effect of task type (\u003cem\u003eF\u003c/em\u003e(3, 120)\u0026thinsp;=\u0026thinsp;21.373, \u003cem\u003ep\u003c/em\u003e \u0026lt; .001, \u003cem\u003eη\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.348) and group (\u003cem\u003eF\u003c/em\u003e(1, 40)\u0026thinsp;=\u0026thinsp;7.263, \u003cem\u003ep\u003c/em\u003e = .010, \u003cem\u003eη\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.154) on valence. There was a significant interaction between group and task type (\u003cem\u003eF\u003c/em\u003e(3, 120)\u0026thinsp;=\u0026thinsp;5.682, \u003cem\u003ep\u003c/em\u003e = .002, \u003cem\u003eη\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.124). Post-hoc comparisons with Bonferroni correction showed that valence ratings were significantly higher in the G-CBT group than in the control group under the reappraisal (\u003cem\u003ep\u003c/em\u003e = .002) and distraction (\u003cem\u003ep\u003c/em\u003e = .011) conditions. These findings indicate that adolescents with NSSI disorder demonstrated improved emotional evaluations of negative images following G-CBT intervention.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section3\"\u003e \u003ch2\u003e3.4.2. Emotion Regulation Questionnaire\u003c/h2\u003e \u003cp\u003eRepeated-measures ANOVA was conducted on reappraisal, with time as a within-subject factor and group as a between-subject factor. The results showed that an insignificant main effect of group (\u003cem\u003eF\u003c/em\u003e(1, 40)\u0026thinsp;=\u0026thinsp;0.810, \u003cem\u003ep\u003c/em\u003e = .374, \u003cem\u003eη\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.020) and a significant main effect of time (\u003cem\u003eF\u003c/em\u003e(1, 40)\u0026thinsp;=\u0026thinsp;6.328, \u003cem\u003ep\u003c/em\u003e = .016, \u003cem\u003eη\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.137) emerged. The results showed that the interaction (\u003cem\u003eF\u003c/em\u003e(1, 40)\u0026thinsp;=\u0026thinsp;0.938, \u003cem\u003ep\u003c/em\u003e =\u0026thinsp;.338, \u003cem\u003eη\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.023; see Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e2\u003c/span\u003eb. A) was insignificant. For suppression, a 2 \u0026times; 2 repeated-measures ANOVA revealed that the main effects of group (\u003cem\u003eF\u003c/em\u003e(1, 40)\u0026thinsp;=\u0026thinsp;4.188, \u003cem\u003ep\u003c/em\u003e = .047, \u003cem\u003eη\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.095) was significant, but the main effects of time (\u003cem\u003eF\u003c/em\u003e(1, 40)\u0026thinsp;=\u0026thinsp;3.285, \u003cem\u003ep\u003c/em\u003e = .077, \u003cem\u003eη\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.076) were insignificant. There was a significant group \u0026times; time interaction (\u003cem\u003eF\u003c/em\u003e (1, 40)\u0026thinsp;=\u0026thinsp;5.430, \u003cem\u003ep\u003c/em\u003e = .025, \u003cem\u003eη\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.120). Post-hoc comparisons with Bonferroni correction indicated that for adolescents with NSSI disorder who received G-CBT treatment, the suppression was significantly lower than for the controls (\u003cem\u003ep\u003c/em\u003e = .003; see Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e2\u003c/span\u003eb. B).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section3\"\u003e \u003ch2\u003e3.4.3. Eye movement in emotional areas of interest\u003c/h2\u003e \u003cdiv id=\"Sec19\" class=\"Section4\"\u003e \u003ch2\u003e3.4.3.1. Fixation count\u003c/h2\u003e \u003cp\u003eThe ANOVA of the fixation counts (see Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e3\u003c/span\u003ea. A) revealed that the group \u0026times; time \u0026times; task type interaction was significant (\u003cem\u003eF\u003c/em\u003e(2, 78)\u0026thinsp;=\u0026thinsp;3.276, \u003cem\u003ep\u003c/em\u003e = .047, \u003cem\u003eη\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.077, Greenhouse-Geisser corrected). After the intervention, the results of group \u0026times; task type repeated-measures ANOVA showed a significant interaction (\u003cem\u003eF\u003c/em\u003e(2, 78)\u0026thinsp;=\u0026thinsp;3.926, \u003cem\u003ep\u003c/em\u003e = .027, \u003cem\u003eη\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.091, Greenhouse-Geisser corrected). Post-hoc comparisons with Bonferroni correction showed that after eight sessions of G-CBT, adolescents with NSSI disorder had more fixation counts for unpleasant images than the controls under reappraisal conditions (\u003cem\u003ep\u003c/em\u003e = .001). For the distraction condition, there was no significant difference in fixation counts between the two groups after G-CBT (\u003cem\u003ep\u003c/em\u003e = .166).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eEye-tracking indices (Emotional Areas of Interest, e-AOI) on the fixation time (FT) and fixation count (FC) for G-CBT and control conditions\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eT1 M(SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eT2 M(SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eView negative\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eReappraisal\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eDistraction\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eView negative\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eReappraisal\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eDistraction\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eG-CBT\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e(n\u0026thinsp;=\u0026thinsp;21)\u003c/b\u003e \u003csup\u003e\u003cb\u003e#\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFT\u003c/p\u003e \u003cp\u003e(ms)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e847.176\u003c/p\u003e \u003cp\u003e(657.496)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e618.825\u003c/p\u003e \u003cp\u003e(499.619)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e563.311\u003c/p\u003e \u003cp\u003e(498.570)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1004.851\u003c/p\u003e \u003cp\u003e(551.360)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e901.916 ***\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e(352.021)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e613.240\u003c/p\u003e \u003cp\u003e(370.902)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.976\u003c/p\u003e \u003cp\u003e(1.959)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.179\u003c/p\u003e \u003cp\u003e(1.469)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.054\u003c/p\u003e \u003cp\u003e(1.592)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4.066\u003c/p\u003e \u003cp\u003e(1.388)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e3.509 ***\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e(1.173)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e2.428\u003c/p\u003e \u003cp\u003e(1.143)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eControl\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e(n\u0026thinsp;=\u0026thinsp;20)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFT\u003c/p\u003e \u003cp\u003e(ms)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e786.027\u003c/p\u003e \u003cp\u003e(602.415)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e552.076\u003c/p\u003e \u003cp\u003e(379.026)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e463.988\u003c/p\u003e \u003cp\u003e(375.887)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e740.646\u003c/p\u003e \u003cp\u003e(514.964)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e466.136\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e(374.255)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e459.911\u003c/p\u003e \u003cp\u003e(488.325)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.262\u003c/p\u003e \u003cp\u003e(1.958)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.363\u003c/p\u003e \u003cp\u003e(1.336)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.041\u003c/p\u003e \u003cp\u003e(1.227)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.229\u003c/p\u003e \u003cp\u003e(1.808)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e2.033\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e(1.371)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1.870\u003c/p\u003e \u003cp\u003e(1.382)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"8\"\u003eNote: T1: Pretreatment; T2: Posttreatment; M: mean; SD: Standard deviation; ms: millisecond.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"8\"\u003e\u003csup\u003e#\u003c/sup\u003e One missing data was observed for the G-CBT condition.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"8\"\u003e***p\u0026thinsp;\u003cem\u003e\u0026lt;\u003c/em\u003e\u0026thinsp;0.001.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section4\"\u003e \u003ch2\u003e3.4.3.2. Fixation time\u003c/h2\u003e \u003cp\u003eRepeated-measures ANOVA on the fixation time (see Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e3\u003c/span\u003ea. B) displayed a marginally significant three-factor interaction (\u003cem\u003eF\u003c/em\u003e(2, 78)\u0026thinsp;=\u0026thinsp;2.556, \u003cem\u003ep\u003c/em\u003e = .057, \u003cem\u003eη\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.061, Greenhouse-Geisser corrected). After the treatment, a 2 \u0026times; 3 repeated-measures ANOVA was conducted. The results illustrated the main effect of both group (\u003cem\u003eF\u003c/em\u003e(2, 78)\u0026thinsp;=\u0026thinsp;4.956, \u003cem\u003ep\u003c/em\u003e = .032, \u003cem\u003eη\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.110) and task type (\u003cem\u003eF\u003c/em\u003e(2, 78)\u0026thinsp;=\u0026thinsp;27.799, \u003cem\u003ep\u003c/em\u003e \u0026lt; .001, \u003cem\u003eη\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.416, Greenhouse-Geisser corrected). There was a significant interaction for group \u0026times; task type (\u003cem\u003eF\u003c/em\u003e(2, 78)\u0026thinsp;=\u0026thinsp;4.957, \u003cem\u003ep\u003c/em\u003e = .012, \u003cem\u003eη\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.113, Greenhouse-Geisser corrected). Bonferroni-corrected post hoc analyses or Post-hoc comparisons with Bonferroni correction revealed that the G-CBT group had longer fixation duration for negative images than the controls under reappraisal conditions (\u003cem\u003ep\u003c/em\u003e \u0026lt; .001). Under the distraction condition, after the intervention, the group difference was insignificant on fixation duration (\u003cem\u003ep\u003c/em\u003e = .239). These findings suggest that G-CBT may be associated with improved emotion regulation, especially reappraisal.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section4\"\u003e \u003ch2\u003e3.4.3.3. Temporal-course analysis\u003c/h2\u003e \u003cp\u003eWe performed a temporal-course analysis to reveal the process of fixation duration on negative images and how this changed over time (see Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e3\u003c/span\u003eb). A 2 \u0026times; 3 \u0026times; 8 repeated-measures ANOVA showed a marginally significant group \u0026times; task type interaction (\u003cem\u003eF\u003c/em\u003e(2, 76)\u0026thinsp;=\u0026thinsp;2.890, \u003cem\u003ep\u003c/em\u003e = .063, \u003cem\u003eη\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.071, Greenhouse-Geisser corrected). Subsequent post hoc comparisons with Bonferroni correction indicated that the G-CBT group spent more time on unpleasant images than the controls under reappraisal conditions (\u003cem\u003ep\u003c/em\u003e = .004). We next conducted an independent-sample t-test. For reappraisal conditions, a significant increase occurred in stages between 0 ms and 1500 ms as well as between 2000 ms and 4000 ms.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section3\"\u003e \u003ch2\u003e3.4.4. Improvements in clinical symptoms\u003c/h2\u003e \u003cdiv id=\"Sec23\" class=\"Section4\"\u003e \u003ch2\u003e3.4.4.1. Depression\u003c/h2\u003e \u003cp\u003eRepeated-measures ANOVA was conducted on HAMD (see Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e2\u003c/span\u003eb, C). There was a main effect of time (\u003cem\u003eF\u003c/em\u003e(1, 40)\u0026thinsp;=\u0026thinsp;4.772, \u003cem\u003ep\u003c/em\u003e = .035, \u003cem\u003eη\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.107) and a significant group \u0026times; time interaction (\u003cem\u003eF\u003c/em\u003e(1, 40)\u0026thinsp;=\u0026thinsp;6.567, \u003cem\u003ep\u003c/em\u003e = .014, \u003cem\u003eη\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.141). Bonferroni-corrected post hoc analyses showed that the G-CBT led to significantly reduced depression symptoms in adolescents with NSSI disorder when compared with the controls (\u003cem\u003ep\u003c/em\u003e = .002).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec24\" class=\"Section4\"\u003e \u003ch2\u003e3.4.4.2. Alexithymia\u003c/h2\u003e \u003cp\u003eThe ANOVA on the efficacy of G-CBT in improving alexithymia displayed a significant interaction between group and time (\u003cem\u003eF\u003c/em\u003e(1, 40)\u0026thinsp;=\u0026thinsp;12.267, \u003cem\u003ep\u003c/em\u003e = .001, \u003cem\u003eη\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.235). After the intervention, the G-CBT resulted in significantly reduced alexithymia in adolescents with NSSI disorder compared with the controls (\u003cem\u003ep\u003c/em\u003e = .001).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec25\" class=\"Section4\"\u003e \u003ch2\u003e3.4.4.3. Associations between alexithymia components and changes in NSSI behaviors\u003c/h2\u003e \u003cp\u003eCorrelation analyses controlling for baseline depression were administered to investigate whether alexithymia components were related to improvement in NSSI behaviors (see Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e3\u003c/span\u003ea). The results showed that difficulty identifying feelings (F1) and difficulty describing feelings (F2) were not significantly related to the improvement of NSSI behaviors after G-CBT. However, the level of EOT (externally oriented thinking, F3) before the intervention was negatively related to two indicators of NSSI (posttreatment minus pretreatment). Linear regression analyses controlling for baseline depression indicated that EOT significantly predicted changes in total and tissue damage behaviors, but did not significantly predict changes in non-tissue damage behaviors (\u003cem\u003eβ\u003c/em\u003e= -0.356, \u003cem\u003ep\u003c/em\u003e = .088; see Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e3\u003c/span\u003eb).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ea Partial correlations between the variables of interest\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e1.TAS-20 (Total)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2.TAS-20 (F1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.690***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3.TAS-20 (F2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.695***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.155\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4.TAS-20 (F3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.354\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.182\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.101\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5.Total (-)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.276\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.131\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.037\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.491*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6.Tissue damage (-)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.333\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.201\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.042\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.519*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.894***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7.No tissue damage (-)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.171\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.041\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.026\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.372\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.909***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.626**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"8\"\u003eNote: Values are partial correlation coefficients controlling for baseline depression (HAMD scores);\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"8\"\u003eF1: Difficulty identifying feelings; F2: Difficulty describing feelings; F3: Externally oriented thinking;\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"8\"\u003e(-): Pretreatment minus posttreatment;\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"8\"\u003e*p\u0026thinsp;\u0026lt;\u0026thinsp;0.05, **p\u0026thinsp;\u0026lt;\u0026thinsp;0.01,, ***p\u0026thinsp;\u0026lt;\u0026thinsp;0.001.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eb Results from prediction analyses\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eBaseline measure\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOutcome\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e \u003cp\u003eCoefficients\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e \u003cp\u003eModel Summary\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBeta\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003et\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eR\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTAS-20 (F3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal (-)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.493\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-2.521*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e.020\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.309\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e4.480*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e.025\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTissue damage (-)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.544\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-2.715*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e.013\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.276\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e3.806*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e.040\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNon-tissue damage (-)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.356\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-1.794\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.088\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.289\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e4.062*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e.033\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"8\"\u003eNote: Baseline depression (HAMD scores) was controlled for in all analyses;\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"8\"\u003eF3: Externally oriented thinking; (-): Pretreatment minus posttreatment;\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"8\"\u003e*p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eWe have demonstrated that G-CBT may improve emotion regulation and reduce NSSI behaviors in adolescents with NSSI disorder. Using an eye-tracking approach, we identified that eight sessions of G-CBT may have contributed to enhanced emotion regulation, mainly manifested as improving emotional ratings for negative images and increasing gaze (i.e., fixation count, fixation time) toward these pictures under reappraisal conditions. According to the temporal-course analysis, after the G-CBT, the fixation time on unpleasant images was significantly increased under reappraisal conditions, which occurred at almost all phases (from 0-1500 ms and 2000\u0026ndash;4000 ms). In addition, compared with the control condition, participants receiving G-CBT showed improvements in depression and alexithymia, along with reductions in NSSI frequency. It was noteworthy that higher levels of EOT predicted poorer improvement in NSSI outcomes. However, these effects should be interpreted with caution. As participants in both groups received usual medication, and non-specific factors such as expectancy or placebo effects cannot be ruled out, the observed changes cannot be attributed solely to the G-CBT intervention.\u003c/p\u003e \u003cp\u003eNotably, the effects of G-CBT were not uniform across different emotion regulation strategies. Contrary to our hypothesis, G-CBT did not significantly improve distraction-based emotion regulation. This may be because the intervention primarily targeted cognitive reappraisal rather than distraction, thus did not directly train distraction. Moreover, meta-analytic evidence suggests that attentional deployment strategies, including distraction, show heterogeneous and sometimes negligible effects on emotional outcomes (Webb et al., \u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e2012\u003c/span\u003e), likely due to variability across subtypes. In addition, improvements in reappraisal may not readily transfer to other strategies, which rely on distinct regulatory processes.\u003c/p\u003e \u003cp\u003eOur results support Gross's process model of emotion regulation. Aligned with the process model (Gross, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2015\u003c/span\u003e), emotion regulation deficits are related to maladaptive performance, whereas the heightened ability to regulate emotion encourages more comfortable moods and adaptive actions (Sheppes, Suri, \u0026amp; Gross, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). In this study, we found an increased gaze time for negative pictures under reappraisal conditions in the G-CBT group compared with the controls. We observed effects on fixation duration during the reappraisal process, indicating the stages of attention deployment and cognitive change, which was in agreement with previous researches (Bebko, Franconeri, Ochsner, \u0026amp; Chiao, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2011\u003c/span\u003e; Dolcos et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). A potential explanation was that the acquisition of enhanced attentional employment after the training dampened the subjective emotional experiences (Dolcos et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2020\u003c/span\u003e), in turn, resulted in greater success in reappraisal and subsequently led to decreased negative emotions (Sanchez, Everaert, \u0026amp; Koster, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). Another possible reason was that reappraisal was associated with a distinct pattern of attention deployment compared to distraction, as individuals engaging in cognitive reappraisal exhibited longer gaze time within the e-AOIs (Bartolomeo, Culbreth, Ossenfort, \u0026amp; Strauss, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). The aforementioned pattern implies that effective reappraisal entails attentional employment toward stimulating content in order to generate an alternative interpretation of the image. Furthermore, neuroimaging provides evidence for the efficacy of G-CBT in developing reappraisal. Prior studies indicated that twelve sessions once weekly of CBT treatment resulted in decreased amygdala reactivity during emotion perception and experience (Gorka et al., \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2019\u003c/span\u003e) and increased activation in reappraisal-related brain regions (e.g., dorsolateral prefrontal cortex, dlPFC) (Goldin et al., \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). In line with this, we found that individuals\u0026rsquo; emotional ratings for unpleasant images were elevated under reappraisal conditions after the intervention. Collectively, adolescents who received CBT treatment can be more flexible in controlling their emotional response using reappraisal. The improvement of emotional regulation allows them to cope with distress and replace self-harm behavior with adaptive activities.\u003c/p\u003e \u003cp\u003eAdditionally, the temporal-course analysis revealed that, after intervention, the gaze time of adolescents with NSSI disorder was improved at almost all phases of reappraisal (between 0 and 1500 ms and between 2000 and 4000 ms). This suggested that the G-CBT group spent more time on unpleasant images from the start of executing the reappraisal strategies, and the improvement was sustained. Although recent research has indicated that reappraisals still effectively regulate negative emotions after controlling the fixation time (Manera, Samson, Pehrs, Lee, \u0026amp; Gross, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e2014\u003c/span\u003e), individuals who shift their eyes from undesired areas tended to show a smaller decrease in negative ratings for unpleasant images (Robinson, Sheen, Sliwinski, Mu, \u0026amp; Compton, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Therefore, it is important to take fixation duration into account when examining the effects of G-CBT on reappraisal in adolescents with NSSI disorder.\u003c/p\u003e \u003cp\u003eRegarding the clinical symptoms, our results documented that the improvements were significant after the intervention. Note that depression often co-occurs with NSSI during the adolescent period (Tilton-Weaver, Marshall, \u0026amp; Svensson, \u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). In our present study, adolescents with NSSI disorder reported greater reductions in depression symptoms after the G-CBT, consistent with previous studies (Kaess et al., \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Slee, Spinhoven, Garnefski, \u0026amp; Arensman, \u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e2008\u003c/span\u003e). Synthetic evidence (LeMoult \u0026amp; Gotlib, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2019\u003c/span\u003e) indicated that cognitive control biases were a trait of depressed individuals, which led to difficulties in cognitive emotion regulation (e.g., reduced frequency of reappraisal). CBT involves reconstructing dysfunctional cognition to improve emotional regulation, which alleviates depressive symptoms. For example, a recent study found that 10 sessions of CBT resulted in depressed individuals being more fixated on happy faces, which is the opposite of unpleasant face images. In addition, improvement in cognitive control was associated with decreased depressive symptoms (Vazquez et al., \u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). Taken together, these findings showed that G-CBT contributed to improving emotional regulation for adolescents with NSSI disorder, thereby reducing their depression.\u003c/p\u003e \u003cp\u003eAfter the intervention, we observed alleviations in NSSI behaviors among adolescents, especially with a significant reduction in tissue damage behaviors. Tissue damage (e.g., cutting and carving the body) is the most common form of self-injury (Nock, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e2010\u003c/span\u003e). Intense physical pain (or bleeding) may have great significance for the relief of negative emotions (Naoum et al., \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e2016\u003c/span\u003e) and for up-regulating positive emotions (Stacy, Pepper, Clapp, \u0026amp; Reyna, \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). It has been argued that self-harm represents an experience avoidance strategy that prevents adaptive cognitive processing of stimuli that cause strong negative emotions (Chapman, Gratz, \u0026amp; Brown, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2006\u003c/span\u003e). Our results suggested that eight sessions of G-CBT decreased the frequency of avoidant strategies and prompted adolescents to use adaptive emotion regulation strategies (i.e., reappraisal) to participate actively in the cognitive processing of unpleasant stimuli. Adaptive emotion regulation strategies reduce the intensity of negative stimuli, allowing the individual to manage negative emotions and further reduce NSSI frequency. Nevertheless, improvement in the frequency of non-tissue injury in the G-CBT group was not significant, mainly due to the small sample size. Another possibility was that, as well as fewer comorbid mental illnesses, individuals with non-tissue injury had less frequent and severe NSSI behaviors, but were susceptible to environmental factors (Whitlock, Muehlenkamp, \u0026amp; Eckenrode, \u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e2008\u003c/span\u003e). These findings suggested that we need to focus on the long-term effects of the G-CBT intervention to prevent recurrence.\u003c/p\u003e \u003cp\u003eInterestingly, our results indicated that alexithymia, especially EOT, affected adolescent NSSI behaviors. EOT refers to people with utilitarian and pragmatic thinking that leads individuals to prefer to make efforts to avoid unpleasant stimuli (Schroeders, Kubera, \u0026amp; Gnambs, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Adolescents with NSSI disorder usually show high EOT (Gatta, Dal Santo, Rago, Spoto, \u0026amp; Battistella, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2016\u003c/span\u003e), which is a particular risk factor for suicide (Ghorbani, Khosravani, Sharifi Bastan, \u0026amp; Jamaati Ardakani, 2017). Likewise, we found that baseline EOT showed a negative correlation with reduced NSSI actions and predicted a smaller improvement after the G-CBT. Higher EOT resulted in adolescents with NSSI disorder obtaining limited gains from G-CBT intervention. Specifically, a high level of EOT may lead to individuals who have not had the opportunity to learn adaptive strategies to handle future challenging events (Davydov, Stewart, Ritchie, \u0026amp; Chaudieu, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2010\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFrom a clinical perspective, the present findings suggest that CBT may improve emotion regulation skills, and diminish depressive symptoms and NSSI behaviors. This reinforces the clinical insights that CBT can modify both emotional regulation and clinical symptoms. Importantly, the EOT dimension of alexithymia was associated with poorer improvement in NSSI, indicating that it may represent a modifiable therapeutic target. This interpretation is supported by prior research showing that alexithymic individuals have significant deficiencies in a particular type of mental state understanding associated with emotional awareness, which greatly limits their ability to grow or change (Demers et al., \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). Encouragingly, tailored short-term interventions have been shown to reduce alexithymia (Cameron, Ogrodniczuk, \u0026amp; Hadjipavlou, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2014\u003c/span\u003e). Taken together, incorporating components that enhance emotional awareness and reduce alexithymia (especially EOT) may further improve the effectiveness of G-CBT in this population.\u003c/p\u003e \u003cp\u003eThe present study integrates eye-tracking methodology within a randomized controlled design to provide an objective, process-level index of attentional deployment during emotion regulation, while prior CBT studies have largely relied on self-report measures or clinician-rated scales to evaluate changes in emotion regulation. By examining gaze patterns toward emotional stimuli under different regulation conditions, this study provides a more fine-grained understanding of the cognitive mechanisms that may underlie therapeutic change. Despite these strengths, several potential limitations should be mentioned in this study. First, the sample size was relatively small, which may have limited statistical power. Second, the absence of follow-up assessments precludes conclusions about the long-term sustainability of the intervention effects. Third, participants were recruited from two urban hospital settings, which may limit representativeness and introduce potential demographic biases (e.g., urban vs. rural populations, socioeconomic status), thereby constraining external validity.\u003c/p\u003e \u003cp\u003eFuture research should aim to replicate these findings in larger, multi-site randomized controlled trials with more diverse samples to enhance generalizability. Moreover, longitudinal follow-up assessments are also needed to determine the durability of treatment effects. In addition, integrating neuroimaging techniques (e.g., fMRI) could help elucidate the neural mechanisms underlying changes in emotion regulation. Finally, ecological momentary assessment may provide a valuable approach to capturing real-time emotion regulation processes and their dynamic relationship with NSSI behaviors in daily life.\u003c/p\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003eIn summary, the results of the current study suggested that G-CBT may be an effective treatment for improving emotion regulation strategies and reducing self-injurious actions in adolescents with NSSI disorder. Certain aspects of alexithymia (i.e., EOT) specifically predicted a reduction in tissue damage. These findings have potential implications for the treatment of adolescents with NSSI disorder.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research was supported by the National Natural Science Foundation of [COUNTRY] (Grant Nos. [XXX, XXX, XXX]), the Ministry of Education Humanities and Social Science Project (Grant No. [XXX]), the Applied Medical Scientific Research Project of [LOCAL HEALTH COMMISSION] (Grant No. [XXX]), and the Clinical Science Foundation of [HOSPITAL NAME] (Grant No. [XXX]).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical Approvals and Statements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Ethics Committee of Anhui Medical University (81220128). All participants provided informed consent; for participants under the age of 18, written informed consent was obtained from their legal guardians in addition to their own assent.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclaration of competing interest\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors report no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors thank all the study participants for their contributions.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eZixuan Guo: Formal analysis, Writing-original draft. Jun Liu: Data curation, Formal analysis. Qiuyu Chen: Investigation. Li Zhu: Resources. Sisi Xie: Resources. Chunyan Zhu: Resources. Fengqiong Yu: Resources. Gong-Jun Ji: Resources, Methodology. Kai Wang: Conceptualization, Funding acquisition. Lei Zhang: Conceptualization, Funding acquisition, Writing-review \u0026amp; editing.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe data that support the findings of this study are available from the corresponding author upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eArmstrong, T., \u0026amp; Olatunji, B. O. (2012). Eye tracking of attention in the affective disorders: A meta-analytic review and synthesis. \u003cem\u003eClin Psychol Rev, 32\u003c/em\u003e(8), 704-723. doi:10.1016/j.cpr.2012.09.004\u003c/li\u003e\n\u003cli\u003eBartolomeo, L. A., Culbreth, A. J., Ossenfort, K. L., \u0026amp; Strauss, G. P. (2020). Neurophysiological evidence for emotion regulation impairment in schizophrenia: The role of visual attention and cognitive effort. \u003cem\u003eJournal of Abnormal Psychology, 129\u003c/em\u003e(6), 670-676. doi:10.1037/abn0000580\u003c/li\u003e\n\u003cli\u003eBebko, G. M., Franconeri, S. L., Ochsner, K. N., \u0026amp; Chiao, J. Y. (2011). Look before you regulate: differential perceptual strategies underlying expressive suppression and cognitive reappraisal. \u003cem\u003eEmotion, 11\u003c/em\u003e(4), 732-742. doi:10.1037/a0024009\u003c/li\u003e\n\u003cli\u003eCameron, K., Ogrodniczuk, J., \u0026amp; Hadjipavlou, G. (2014). Changes in alexithymia following psychological intervention: a review. \u003cem\u003eHarv Rev Psychiatry, 22\u003c/em\u003e(3), 162-178. doi:10.1097/HRP.0000000000000036\u003c/li\u003e\n\u003cli\u003eCarter, B. T., \u0026amp; Luke, S. G. (2020). Best practices in eye tracking research. \u003cem\u003eInt J Psychophysiol, 155\u003c/em\u003e, 49-62. doi:10.1016/j.ijpsycho.2020.05.010\u003c/li\u003e\n\u003cli\u003eChapman, A. L., Gratz, K. L., \u0026amp; Brown, M. Z. (2006). 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Promoting gaze toward the eyes of emotional faces in individuals with high autistic traits using group cognitive behavioral therapy: An eye-tracking study. \u003cem\u003eJournal of affective disorders, 306\u003c/em\u003e, 115\u0026ndash;123. https://doi.org/10.1016/j.jad.2022.03.023\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"cognitive-therapy-and-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"cotr","sideBox":"Learn more about [Cognitive Therapy and Research](http://link.springer.com/journal/10608)","snPcode":"10608","submissionUrl":"https://www.editorialmanager.com/cotr/default.aspx","title":"Cognitive Therapy and Research","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Non-suicidal self-injury, Emotion regulation, Reappraisal, Group Cognitive-Behavioral Therapy, Eye-tracking","lastPublishedDoi":"10.21203/rs.3.rs-9392047/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9392047/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Non-suicidal self-injury (NSSI) is prevalent among adolescents and is associated with emotion regulation deficits. This study aimed to examine the effects of group cognitive behavioral therapy (G-CBT) on emotion regulation in adolescents with NSSI disorder and whether enhanced emotion regulation ability could reduce NSSI behaviors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethod: \u003c/strong\u003eParticipants were adolescents with NSSI disorder (G-CBT: n = 27; Control: n = 27). In addition to standard pharmacotherapy, the G-CBT group underwent eight sessions of G-CBT, twice a week. The control group received pharmacotherapy only. Clinical scales and eye-tracking data was collected before and after the intervention. The primary outcomes were NSSI frequency, with secondary outcomes including emotion regulation, eye-tracking indices, depression and alexithymia.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e In contrast to the control group, the G-CBT group indicated a significant reduction in NSSI frequency and depressive symptoms after intervention, along with marked improvements in emotion regulation and alexithymia. Eye-tracking results showed that during cognitive reappraisal, the G-CBT group exhibited longer gaze durations toward negative stimuli, particularly in the early (0-1500 ms) and late (2000-4000 ms) stages, reflecting enhanced emotional engagement. Furthermore, higher baseline levels of externally oriented thinking (EOT) predicted poorer improvement in NSSI behaviors following G-CBT.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e These findings suggest that G-CBT may be effective in reducing NSSI behaviors and improving emotion regulation, with EOT representing a potential therapeutic target.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical Trial Registration: \u003c/strong\u003eChinese Clinical Trial Registry (ChiCTR2500103826).\u003c/p\u003e","manuscriptTitle":"The efficacy of cognitive behavioral therapy (CBT) in improving emotion regulation and self-injurious behavior in adolescents with non-suicidal self-injury (NSSI)","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-05-04 08:24:18","doi":"10.21203/rs.3.rs-9392047/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-05-18T18:14:53+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-12T16:06:30+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"191078447914871978791936128599544130221","date":"2026-04-23T15:53:07+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"45023904485494683964350685102939003372","date":"2026-04-22T09:39:41+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"87107604800912701792589945110536813111","date":"2026-04-21T20:22:50+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-21T19:04:46+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-04-16T05:09:44+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-04-16T05:09:35+00:00","index":"","fulltext":""},{"type":"submitted","content":"Cognitive Therapy and Research","date":"2026-04-12T06:19:28+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"cognitive-therapy-and-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"cotr","sideBox":"Learn more about [Cognitive Therapy and Research](http://link.springer.com/journal/10608)","snPcode":"10608","submissionUrl":"https://www.editorialmanager.com/cotr/default.aspx","title":"Cognitive Therapy and Research","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"c8539c49-7122-4d8b-aa79-739b9ab00ae6","owner":[],"postedDate":"May 4th, 2026","published":true,"recentEditorialEvents":[{"type":"editorInvitedReview","content":"","date":"2026-05-18T18:14:53+00:00","index":36,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-12T16:06:30+00:00","index":35,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-04T08:24:22+00:00","versionOfRecord":[],"versionCreatedAt":"2026-05-04 08:24:18","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9392047","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9392047","identity":"rs-9392047","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}