Self-injury, also known as self-harm or non-suicidal self-injury (NSSI), is the act of deliberately inflicting harm on one’s own body without suicidal intent. It’s a behavior typically used as a coping mechanism to deal with emotional pain, stress, or trauma.
How common is non-suicidal self-injury?
Self-injury is more common among adolescents and young adults, though it can occur at any age. Studies suggest varying prevalence rates, but it’s estimated that the lifetime prevalence of self-injury in adolescents is between 16% and 22%, with women being more likely to engage in self-injurious behaviors. It does occur in all demographic groups, regardless of gender, race, or socio-economic background.
Related: Non-Suicidal Self-Injury in Adolescents and Adults
Forms of non-suicidal self-injuries
- Cutting or scratching the body with a sharp object
- Burning oneself with matches, cigarettes, or hot objects
- Punching or striking oneself, sometimes using objects
- Pulling out hair
- Picking skin or wounds and preventing them from healing
- Piercing skin with sharp objects
If non-suicidal self-injuries are suspected, it’s important to approach the situation with empathy and understanding.
DSM-5 classification of non-suicidal self-injuries
The historical classification and understanding of self-injury have evolved significantly over time, leading to its inclusion in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) as a condition warranting further study. Here’s a brief overview of this evolution:
Early understanding
Historically, self-injury was often misunderstood and sometimes linked to religious or cultural practices. In the medical and psychological fields, it was initially seen as a symptom of other mental disorders, particularly borderline personality disorder, and not as a distinct condition.
Over time, as research into self-harm expanded, it became clear that it could occur in individuals without any other diagnosable mental health disorder. This realization led to a shift in how self-injury was perceived, separating it from being just a symptom of other conditions.
DSM-5 inclusion
With the publication of the DSM-5 in 2013, self-injury was included in Section III, which is dedicated to conditions that require further research. It was listed as “Non-suicidal Self-Injury” (NSSI) to differentiate it from self-harming behaviors with suicidal intent. The inclusion of NSSI as a condition for further study reflects an acknowledgment of its distinct nature and the need for more research into its diagnosis and treatment.
Implications of non-suicidal self-injuries
The inclusion in the DSM-5 has important implications for treatment and insurance coverage. It opens more avenues for research and helps in developing targeted therapies. It also helps in reducing the stigma associated with self-injury, recognizing it as a mental health issue deserving attention and empathy.
The inclusion of NSSI in the DSM-5 marks a significant step in understanding and addressing non-suicidal self-injuries as a complex mental health issue, separate from other diagnoses. It highlights the need for specialized attention, research, and treatment strategies for individuals who engage in self-injurious behaviors.
Developmental trajectory of self-injury
The developmental trajectories of non-suicidal self-injuries in adolescents and adults can vary significantly based on individual circumstances, environmental factors, and underlying mental health issues. However, there are some common patterns and stages that have been observed.
Adolescents
Self-injury often begins in early to mid-adolescence, usually around the preteen or early teen years of 12-14. The onset is frequently linked to the onset of puberty and the associated emotional and psychological changes.
The behavior typically peaks in late adolescence, around 16, and starts decreasing after 18 years old. It often starts as an impulsive act during a period of stress or emotional turmoil. Adolescents may continue self-injuring regularly or intermittently as a coping mechanism.
Factors influencing non-suicidal self-injury
Peer relationships, family dynamics, academic pressures, and social media influence can significantly impact the development and continuation of self-injury. Adolescents with a history of trauma, abuse, or mental health disorders like depression or anxiety are at higher risk.
For some, self-injury decreases or stops as they enter adulthood and develop more effective coping mechanisms. However, for others, it can persist into adult life, especially in the absence of appropriate intervention and support.
NSSI in adults
Adults who continue self-injuring often have a history of starting in adolescence. The nature of self-injury can become more severe or ritualistic over time.
While less common, some adults may start self-injuring later in life, often in response to significant life stressors or mental health issues. Adult-onset self-injury can be linked to life events like relationship breakdowns, job loss, or bereavement. In adults, self-injury may be more chronic and can co-occur with other mental health disorders, such as borderline personality disorder, major depression, or eating disorders. Adults might engage in more severe forms of self-harm and are often more adept at hiding their behavior.
In both adolescents and adults, self-injury should be taken seriously as a sign of emotional distress and not simply a ‘phase’ or attention-seeking behavior. Understanding these developmental trajectories can aid in providing age-appropriate and effective support and treatment.
Risk factors contributing to the development of non-suicidal self-injuries
Self-injury is a complex behavior influenced by various factors. It serves multiple functions for those who engage in it. It also carries several health consequences.
What factors contribute to the development of NSSI?
Mental health disorders, such as depression, anxiety, borderline personality disorder, or post-traumatic stress disorder, have a higher likelihood of contributing to the development of non-suicidal self-injuries. Other risk factors that may contribute to self-harm include:
- History of trauma or abuse, including physical, sexual, or emotional abuse.
- Stressful life events, like family conflict, bullying, or the death of a loved one.
- Peer influence, especially among adolescents, where self-injury can sometimes be ‘contagious’ within social groups.
- Low self-esteem or feelings of worthlessness.
- Difficulty expressing feelings verbally, leading to using self-injury as a form of expression.
- A history of other impulsive or risky behaviors.
Possible functions of self-injury
Non-suicidal self-injury often has a purpose and function for those who engage in these behaviors. The possible functions of non-suicidal self-injury might include:
- Emotion regulation. To manage or reduce severe emotional distress or anxiety. To interrupt overwhelming emotional states or thoughts.
- Self-punishment. As a means of expressing self-directed anger or disgust. To punish oneself for perceived faults or failures.
- Communication. To express distress to others or as a cry for help. To communicate what may be difficult to verbalize.
- Sense of control. To regain control over one’s body or emotions in situations where they feel powerless. To create a physical manifestation of internal pain.
- Dissociation and numbing. To counteract feelings of numbness or dissociation by inducing physical pain. To feel ‘real’ or ‘alive’ through self-inflicted pain.
Health consequences of self-injury
Self-injury, while a coping mechanism for some, can lead to many serious consequences. These span physical, psychological, social, and even potentially suicidal outcomes.
Physically, non-suicidal self-injuries can leave lasting scars and disfigurement from cuts, burns, or other injuries. These behaviors can also heighten the risk of severe and life-threatening infections, not to mention the possibility of accidental severe injuries.
Psychologically, this behavior often exacerbates feelings of shame, guilt, and low self-esteem, potentially leading to a harmful cycle of emotional distress and further self-injury. It may also worsen any underlying mental health conditions.
Non-suicidal self-injury is different from suicidal behavior. But chronic engagement in self-injury can significantly increase the risk of developing suicidal thoughts and attempts, particularly if the root causes and issues are not adequately addressed.
It’s crucial to understand that self-injury is often a symptom of deeper emotional pain or psychological issues. Effective intervention requires addressing not only the physical aspect of self-injury but also the underlying emotional and psychological factors.
Assessing self-injurious behaviors
Assessing self-injurious thoughts and behaviors involves a comprehensive approach that considers the individual’s mental and emotional state, history, and the specifics of their self-injurious actions. Here are key steps and methods used in such assessments:
- Clinical interview. Start with broad, open-ended questions to establish rapport and encourage the individual to talk freely about their experiences and feelings. After establishing a comfortable dialogue, ask direct but sensitive questions about self-injurious behaviors, including the methods, frequency, and triggers. Then evaluate the risk of severe injury or suicidal behavior. Determine if the individual has a plan or intent to harm themselves severely or attempt suicide. Discuss the individual’s personal and family history, including any history of mental health issues, trauma, or abuse.
- Behavioral observations. Pay attention to non-verbal cues that might indicate distress or reluctance to talk about certain topics. Look for visible signs of self-injury, such as scars, fresh wounds, or bandages.
- Psychological assessments. Use standardized tools and questionnaires designed to assess self-injurious behaviors and associated psychological factors like depression, anxiety, and stress. Assessments like the Non-Suicidal Self-Injury Assessment Tool (NNSI-AT) and the Columbia-Suicide Severity Rating Scale (CSSRS) can help in assessing severity of self-harm and suicidal intent. Assessing co-occurring mental health disorders, which are common in individuals who self-injure, is also important in addressing self-injury.
- Safety planning. If there’s an immediate risk of harm, develop a safety plan. This may involve hospitalization or increased supervision. For long-term management, collaborate with the individual to develop strategies to avoid self-injury, such as using alternative coping mechanisms.
Collaboration with other professionals
In some cases, it may be beneficial to collaborate with other healthcare professionals, such as psychiatrists, psychologists, and social workers. If appropriate and with the individual’s consent, also involve family members in the treatment process to provide support and understand the individual’s struggles. Assessing self-injurious thoughts and behaviors requires a sensitive, empathetic, and comprehensive approach. It’s important to create a safe and non-judgmental environment where individuals feel comfortable discussing their experiences.
The difference between NSSI and other comorbidities
Differentiating self-injury from other diagnoses and understanding its comorbidities is crucial in the field of mental health. Non-suicidal self-injury can be a standalone behavior or occur alongside other mental health conditions.
Differentiating self-injury from other diagnoses
- Self-injury vs. suicidal behavior. The key distinction between self-injury and suicidal behavior lies in intent. NSSI is typically done without suicidal intent; it’s more about coping with emotional pain or stress. In contrast, suicidal behavior is an act with the intention to end one’s life. Suicidal attempts are often more lethal and planned, whereas self-injury usually involves less lethal methods like cutting or scratching.
- Self-injury vs. Borderline Personality Disorder (BPD). While self-injury is a common symptom of BPD, not everyone who self-injures has BPD. BPD is characterized by a broader range of symptoms, including intense and unstable relationships, self-image issues, and impulsive behaviors. NSSI can occur without the presence of the other symptoms necessary for a BPD diagnosis.
- Self-injury vs. substance abuse. Substance abuse involves the misuse of drugs or alcohol, which is different from the direct physical harm seen in self-injury. However, both behaviors may serve similar purposes, such as coping with emotional distress or providing a temporary escape.
Comorbidities with self-injury
- Depression and anxiety: These conditions commonly co-occur with self-injury. Individuals may use NSSI to manage overwhelming feelings associated with these conditions.
- Eating disorders: There’s a notable overlap between self-injury and eating disorders, both of which involve harmful body-focused behaviors and issues with self-image.
- Trauma and PTSD: Individuals with a history of trauma, particularly childhood abuse or neglect, may be more likely to engage in self-injury as a coping mechanism.
Proper diagnosis is crucial to addressing non-suicidal self-injuries, as it guides the treatment plan and helps healthcare providers address not only the self-injury but also any underlying or associated conditions.
Treatment approaches for non-suicidal self-injury
Treating self-injury involves an approach that addresses behavior and the underlying psychological issues. Treatment typically includes a combination of psychotherapy, medication (if necessary), and support strategies.
Psychotherapy
Psychotherapy is often the primary mode of treatment for self-injury. Different types of therapy can be effective:
- Cognitive Behavioral Therapy (CBT): Focuses on identifying and changing negative thought patterns and behaviors. It helps individuals develop healthier coping strategies.
- Dialectical Behavior Therapy (DBT): Particularly effective for individuals with self-injury behaviors, especially those with BPD. DBT combines cognitive-behavioral techniques with mindfulness and focuses on improving emotional regulation, distress tolerance, and interpersonal effectiveness.
Medication
While there are no specific medications to treat self-injury, medications might be prescribed to address underlying or associated psychiatric conditions:
- Antidepressants: For individuals with depression or anxiety.
- Mood stabilizers: Can be helpful for those with mood swings or bipolar disorder.
- Antipsychotics: Particularly where there are symptoms of psychosis or severe emotional dysregulation.
Skill building and education
- Teaching coping and emotion-regulation skills to help manage the triggers of self-injury
- Mindfulness and distress tolerance skills are often taught as part of therapy
- Educating the individual and their family about self-injury and its underlying causes
- Support groups or peer support can provide additional layers of understanding and community
Treatment for self-injury needs to be personalized, as the underlying causes and factors can vary greatly from person to person. A combination of these approaches forms the cornerstone of effective treatment. Building a trustworthy and supportive therapeutic relationship is also key in encouraging individuals to engage in and adhere to treatment.
Conclusion
Understanding non-suicidal self-injury is vital not only for providing appropriate care and support to those who engage in it but also for breaking down the stigma and misconceptions surrounding this behavior. Recognizing NSSI as a complex response to emotional distress rather than a mere attention-seeking action can foster empathy and encourage open, non-judgmental conversations.
Ultimately, a deeper awareness and comprehension of non-suicidal self-injuries are key steps in preventing the escalation of self-injurious behaviors.
