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Nonsuicidal Self-Injury

By Paula J. Clayton, MD

Nonsuicidal self-injury is a self-inflicted act that causes pain or superficial damage but is not intended to cause death.

Although the methods people use to hurt themselves, such as cutting their wrists with a razor blade, sometimes overlap with those of suicide attempts, nonsuicidal self-injury is different because people do not intend the acts to cause death. Often, people specifically state that they are not trying to kill themselves. In other cases, doctors presume people are not actually trying to die when they repeatedly do something that clearly cannot cause death—for example, burning themselves with cigarettes. However, the first time people hurt themselves, it may not be clear whether they actually intended to die. For example, people may think that they could kill themselves by taking an overdose of antibiotics or vitamins, take such dose, and then realize that such a dose is harmless.

Even when self-injury does not cause death, people who injure themselves are probably more likely over the long term to attempt or commit suicide. Thus, doctors and family members should not lightly dismiss nonsuicidal self-injury.

Nonsuicidal self-injury tends to start during early adolescence. It is more common among people who have other disorders, particularly borderline personality disorder, eating disorders, and substance abuse. Unlike in suicidal behavior, which is much more common among girls, nonsuicidal self-injury is more equally balanced among boys and girls, although it is still slightly more common among girls (and women). Most people stop hurting themselves when they get older.

People often injure themselves repeatedly in a single session, creating several cuts or burns in the same location. Usually, people choose a visible or accessible area, such as the forearms or front of the thighs. Typically, people also hurt themselves repeatedly, resulting in extensive scars from previous episodes. People are often preoccupied with thoughts about the injurious acts.

Why people injure themselves is unclear, but self-injury may be a way to reduce tension or negative feelings, a way to resolve interpersonal difficulties, self-punishment for perceived faults, or a plea for help.

Some people do not think their self-injury is a problem and thus tend not to seek or accept counseling.

Diagnosis

  • A doctor's evaluation

Diagnosis of nonsuicidal self-injury must exclude suicidal behavior.

If people do not think their self-injury is a problem, they may be reluctant to talk about it. Thus, to evaluate people who have injured themselves, doctors first try to help these people talk about their self-injury. To do so, doctors communicate the following:

  • That they have heard the person and take the person's experiences seriously

  • That they understand how the person feels and how those feelings could result in self-injury

Doctors then try to determine the following:

  • How people injure themselves and how many different ways they do it (for example, do they burn and cut themselves?)

  • How often they injure themselves

  • How long they have been injuring themselves

  • What purpose does injuring themselves serve

  • How willing they are to participate in treatment

Doctors also check for other mental health disorders, such as borderline personality disorder and try to estimate how likely people are to attempt suicide.

Treatment

  • Certain types of psychotherapy

  • Treatment of any other disorders present

Certain types of psychotherapy may help people who injure themselves. They include

  • Dialectical behavior therapy

  • Emotion regulation group therapy

Dialectical behavior therapy provides weekly individual and group sessions for 1 year and a therapist who is available 24 hours a day by telephone. The therapist acts as a behavior coach. The aim is to help people find more appropriate ways of responding to stress—for example, to resist urges to behave self-destructively.

Emotion regulation group therapy involves 14 weeks of group therapy. It helps people become aware of, understand, and accept their emotions. This therapy helps people be willing to accept negative emotions as part of life and thus not to respond to such emotions so intensely and impulsively.

No drugs have been approved for the treatment of nonsuicidal self-injury. However, naltrexone and certain atypical antipsychotics have been effective in some people.

If people have other mental health disorders (such as depression, eating disorders, substance abuse, or borderline personality disorder), such disorders are treated. If needed, people should be referred to a mental health care practitioner. Follow-up appointments are essential.

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