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Nonsuicidal Self-Injury (NSSI)

By

Christine Moutier

, MD, American Foundation For Suicide Prevention

Last full review/revision Jun 2021| Content last modified Jun 2021
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Nonsuicidal self-injury is a self-inflicted act that causes pain or superficial damage but is not intended to cause death.

Although the methods used sometimes overlap with those of suicide attempts (eg, cutting the wrists with a razor blade), nonsuicidal self-injury is distinct from suicide Suicidal Behavior Suicide is death caused by an intentional act of self-harm that is designed to be lethal. Suicidal behavior encompasses a spectrum of behavior from suicide attempt and preparatory behaviors... read more because patients do not intend the acts to be lethal. Patients may specifically state a lack of intent, or the lack may be inferred by their repeated use of clearly nonlethal methods. Despite the lack of immediate lethality, long-term risk of suicide attempts and of suicide completion is increased, and thus, nonsuicidal self-injury should not be dismissed lightly.

The most common examples of nonsuicidal self-injury include

  • Cutting or stabbing the skin with a sharp object (eg, knife, razor blade, needle)

  • Burning the skin (typically with a cigarette)

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.

Nonsuicidal self-injury tends to start in the early teens (1 General reference Nonsuicidal self-injury is a self-inflicted act that causes pain or superficial damage but is not intended to cause death. Although the methods used sometimes overlap with those of suicide attempts... read more ), and although data are not conclusive, may be slightly more prevalent in females, unlike suicide attempts, which are much more common in girls. The natural history is unclear, but the behavior appears to decrease after young adulthood. Prevalence is also high in criminal populations, which tend to be predominantly male.

The motivations for nonsuicidal self-injury 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

Some patients view the self-injury as a positive activity and thus tend not to seek or accept counseling.

Nonsuicidal self-injury is often accompanied by other disorders, particularly borderline personality disorder Borderline Personality Disorder (BPD) Borderline personality disorder is characterized by a pervasive pattern of instability and hypersensitivity in interpersonal relationships, instability in self-image, extreme mood fluctuations... read more , antisocial personality disorder Antisocial Personality Disorder (ASPD) Antisocial personality disorder is characterized by a pervasive pattern of disregard for consequences and for the rights of others. Diagnosis is by clinical criteria. Treatment may include cognitive-behavioral... read more , eating disorders Introduction to Eating Disorders Eating disorders involve a persistent disturbance of eating or of behavior related to eating that Alters consumption or absorption of food Significantly impairs physical health and/or psychosocial... read more , alcohol Alcohol Use Disorders and Rehabilitation Alcohol use disorder involves a pattern of alcohol use that typically includes craving and manifestations of tolerance and/or withdrawal along with adverse psychosocial consequences. Alcoholism... read more and substance use disorders Substance Use Disorders Substance use disorders are a type of substance-related disorder that involve a pathologic pattern of behaviors in which patients continue to use a substance despite experiencing significant... read more , and autism Autism Spectrum Disorders Autism spectrum disorders are neurodevelopmental disorders characterized by impaired social interaction and communication, repetitive and stereotyped patterns of behavior, and uneven intellectual... read more .

General reference

  • 1. 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

Diagnosis of Nonsuicidal Self-Injury

  • Exclusion of suicidal behavior

  • Assessment of self-injury

Diagnosis of nonsuicidal self-injury must exclude suicidal behavior.

Assessment of nonsuicidal self-injury, 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 nonsuicidal self-injury should include the following:

  • Determining what type of self-injury and how many types of self-injury the patient has inflicted

  • Determining how often nonsuicidal self-injury occurs and how long it has been occurring

  • Determining the function of nonsuicidal self-injury 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

Treatment of Nonsuicidal Self-Injury

  • Sometimes certain forms of cognitive-behavioral therapy

  • Treatment of coexisting disorders

The following cognitive-behavioral therapies may be useful for treating nonsuicidal self-injury:

  • Dialectical behavioral therapy (DBT)

  • Emotion-regulation group therapy (ERGT)

DBT involves individual and group therapy for 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).

ERGT 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. ERGT helps patients 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 patients.

Follow-up appointments should be scheduled.

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