Nonsuicidal self-injurious behaviors occur mostly in adolescents and can include superficial scratching, cutting, or burning the skin (using cigarettes or curling irons), as well as stabbing, hitting, and repeated rubbing of the skin with an eraser or salt, in the absence of an intent to die.
Nonsuicidal self-injury (NSSI) is the intentional act of causing physical harm to oneself without the intention to end one’s life. Some but not all (1) of adolescents with NSSI have other co-occurring disorders such as mood disorders (2), anxiety disorders (3), poor self-esteem (4), eating disorders (5), PTSD (3), personality disorders (2, 3), and substance use disorders (6, 7).
In children and adolescents, NSSI can manifest in various forms, such as cutting, burning, hitting, or using other methods of self-inflicted injury without a lethal intent. In many adolescents, self-injurious behaviors do not indicate suicidality but instead are self-punishing actions that they may feel they deserve; these behaviors are used to gain the attention of parents and/or significant others, express anger, regulate negative emotions, or identify with a peer group. However, these adolescents, especially those who have used multiple methods of self-harm, are likely to have other co-occurring psychiatric disorders and increased risk of suicide (4, 8).
All self-injurious behaviors should be evaluated by a clinician experienced in working with troubled children and adolescents to assess whether suicidality is an issue and to identify the underlying distress leading to the self-injurious behaviors (9). Addressing NSSI in children and adolescents typically involves therapeutic interventions that may include cognitive-behavioral therapy (CBT), dialectical behavior therapy (DBT), and other therapeutic modalities aimed at improving coping skills and emotional regulation.
Patients often injure themselves repeatedly in a single session, creating multiple lesions in the same location, typically in areas that are easily hidden but accessible (eg, forearms, front of thighs). The behavior is often repeated, resulting in extensive patterns of scarring. Patients are often preoccupied with thoughts about the injurious acts.
NSSI typically starts in early adolescence. Rates from general population studies are similar between men and women. The natural history is unclear, but the behavior appears to decrease after young adulthood (10). Prevalence is also high in criminal populations, which tend to be predominantly male (11).
The motivations for NSSI are 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
A plea for help
General references
1. Swannell SV, Martin GE, Page A, et al. Prevalence of nonsuicidal self-injury in nonclinical samples: Systematic review, meta-analysis and meta regression. Suicide Life Threat Behav. 44(3):273-303, 2013. doi: 10.1111/sltb.12070
2. Cox LJ, Stanley BH, Melhem NM, et al. Familial and individual correlates of nonsuicidal self-injury in the offspring of mood-disordered parents. J Clin Psychiatry. 73(6):813-820, 2012. doi: 10.4088/JCP.11m07196
3. Nock MK, Joiner TE, Gordon KH, et al. Nonsuicidal self-injury among adolescents: Diagnostic correlates and relation to suicide attempts. Psychiatry Res. 144(1):65-72, 2006. doi: 10.1016/j.psychres.2006.05.010
4. Lewis SP, Heath NL. Nonsuicidal self-injury among youth. J Pediatr. 166(3):526-530, 2015. doi: 10.1016/j.jpeds.2014.11.062
5. Cipriano A, Cella S, Cotrufo P. Nonsuicidal self-injury: A systematic review. Front Psychol. 8:1946, 2017. doi: 10.3389/fpsyg.2017.01946
6. Nock MK, Prinstein MJ. Contextual features and behavioral functions of self-mutilation among adolescents. J Abnorm Psychol. 114(1):140-146, 2005. doi: 10.1037/0021-843X.114.1.140
7. Lloyd-Richardson EE, Perrine N, Dierker L, et al. Characteristics and functions of non-suicidal self-injury in a community sample of adolescents. Psychol Med. 37(8):1183-1192, 2007. doi: 10.1017/S003329170700027X
8. Greydanus DE, Apple RW. The relationship between deliberate self-harm behavior, body dissatisfaction, and suicide in adolescents: Current concepts. J Multidiscip Healthc. 4:183-189, 2011. doi: 10.2147/JMDH.S11569
9. Brown RC, Plener PL. Non-suicidal self-injury in adolescence. Curr Psychiatry Rep.19(3):20, 2017. doi: 10.1007/s11920-017-0767-9
10. Klonsky ED, Victor SE, Saffer BY. Nonsuicidal self-injury: What we know, and what we need to know. Can J Psych. 59(11):565-568, 2014. doi: 10.1177/070674371405901101
11. Favril L. Non-suicidal self-injury and co-occurring suicide attempt in male prisoners. Psychiatry Res. 2019;276:196-202. doi:10.1016/j.psychres.2019.05.017
Diagnosis of Nonsuicidal Self-Injury in Children and Adolescents
Diagnostic and Statistical Manual of Mental Disorders, Fifth edition, Text Revision (DSM-5-TR) criteria
Exclusion of suicidal behavior
Assessment of self-injury
Diagnosis of NSSI must necessarily exclude suicidal behavior. The diagnosis involves the presence intentionally causing self-inflicted bodily harm (eg, cutting, burning) at least 5 times in the past year, without suicidal intent, primarily to gain relief from negative feelings, solve interpersonal problems, or induce positive emotions (1). For the condition to be diagnosed, the behavior must also cause significant distress or functional impairment and is not socially sanctioned or part of another mental or medical condition.
Assessment of NSSI, as for suicidal behavior, is essential before treatment begins.
Facilitating discussion of the self-injury with the patient is essential to adequate assessment and helps physicians plan treatment. Physicians can facilitate such discussions by doing the following:
Validating the patient's experience by communicating that they have heard the patient and take the patient's experiences seriously
Understanding the patient's emotions (eg, confirming that the patient's emotions and actions are understandable in light of the patient's circumstances)
Assessment of NSSI should include the following:
Determining what type of self-injury and how many types of self-injury the patient has inflicted
Determining how often NSSI occurs and how long it has been occurring
Determining the function of NSSI for the patient
Checking for coexisting psychiatric disorders
Estimating the risk of a suicide attempt
Determining how willing the patient is to participate in treatment
Diagnosis reference
1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR), Washington: American Psychiatric Association, 2022.
Treatment of Nonsuicidal Self-Injury in Children and Adolescents
Certain forms of psychotherapy (eg, cognitive behavioral therapy, dialectical behavioral therapy, emotion-regulation group therapy)
Rarely pharmacotherapy
Treatment of coexisting disorders
The treatment of NSSI in children and adolescents typically involves a combination of psychotherapy, such as cognitive-behavioral therapy, and family support, aimed at addressing underlying emotional issues and developing healthier coping strategies (1). In rare instances, medications can be effective. Cognitive behavioral therapy is typically done as outpatient, individual therapy, but it can also be done in groups in an inpatient setting. Improvement occurs by helping patients change the ways they respond to their automatic thoughts, and unlinking negative thought-behavior-mood patterns.
Dialectical behavioral therapy involves individual and group therapy for at least 1 year. This therapy focuses on identifying and trying to change negative thinking patterns and promoting positive changes. It aims to help patients find more appropriate ways of responding to stress (eg, to resist urges to behave self-destructively).
Emotion-regulation group therapy is done in a 14-week group setting. This therapy involves teaching patients how to increase awareness of their emotions and provides them with skills to deal with their emotions. Emotion-regulation group therapy helps patients accept negative emotions as part of life and thus not to respond to such emotions so intensely and impulsively.
No medications have been approved specifically for the treatment of NSSI in the United States. However, naltrexone and certain second-generation antipsychotics have been effective in some patients (No medications have been approved specifically for the treatment of NSSI in the United States. However, naltrexone and certain second-generation antipsychotics have been effective in some patients (1).
Coexisting psychiatric disorders (eg, depression, eating disorders, substance use disorders, borderline personality disorder, bipolar disorder) should be treated appropriately. Patients should be referred to an appropriate clinician as needed.
Follow-up appointments should be scheduled.
Treatment reference
1. Turner BJ, Austin SB, Chapman AL. Treating nonsuicidal self-injury: a systematic review of psychological and pharmacological interventions. Can J Psychiatry. 2014;59(11):576-585. doi:10.1177/070674371405901103
Drugs Mentioned In This Article
