Merck Manual

Please confirm that you are a health care professional

honeypot link

Nonsuicidal Self-Injury (NSSI)


Christine Moutier

, MD, American Foundation For Suicide Prevention

Last full review/revision Jun 2021| Content last modified Jun 2021
Click here for Patient Education

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 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), 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, antisocial personality disorder, eating disorders, alcohol and substance use disorders, and autism.

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.

Coexisting psychiatric disorders (eg, depression, eating disorders, substance use disorders, borderline personality disorder, antisocial personality disorder) should be treated appropriately. Patients should be referred to an appropriate health care practitioner as needed.

Follow-up appointments should be scheduled.

Click here for Patient Education
NOTE: This is the Professional Version. CONSUMERS: Click here for the Consumer Version


Professionals also read

Test your knowledge

Somatic Symptom Disorder
Patients with somatic symptom disorder are commonly referred to a psychiatrist even if they have a supportive relationship with their physician. The primary intervention of the psychiatrist is to provide psychotherapy to the patient. Which of the following types of psychotherapy is most likely used in patients with this disorder? 
Download the Manuals App iOS ANDROID
Download the Manuals App iOS ANDROID
Download the Manuals App iOS ANDROID
Download the Manuals App iOS ANDROID
Download the Manuals App iOS ANDROID
Download the Manuals App iOS ANDROID

Also of Interest

Download the Manuals App iOS ANDROID
Download the Manuals App iOS ANDROID
Download the Manuals App iOS ANDROID