Evidence-Based Reviews

Nonsuicidal self-injury: How categorization guides treatment

Current Psychiatry. 2012 March;11(3):21-26

Understanding how and why patients engage in NSSI leads to optimal care

References

1. Walsh BW, Rosen PM. Self-mutilation: theory research, and treatment. New York, NY: Guilford Press; 2008:32.

2. Nock MK, Favazza AR. Nonsuicidal self-injury: definition and classification. In: Nock MK ed. Understanding nonsuicidal self-injury: origins, assessment, and treatment. Washington, DC: American Psychological Association; 2009:9-18.

3. Favazza AR, Conterio K. Female habitual self-mutilators. Acta Psychiatr Scand. 1989;79(3):283-289.

4. Favazza A. Bodies under siege: self-mutilation nonsuicidal self-injury, and body modification in culture and psychiatry. 3rd ed. Baltimore, MD: Johns Hopkins University Press; 2011.

5. Gallina R. Tattoos and body piercing. In: Vale V Juno A, eds. Modern primitives. San Francisco, CA: Re/Search Publications; 1989:101-105.

6. Chapman AL, Gratz KL, Brown MZ. Solving the puzzle of deliberate self-harm: the experiential avoidance model. Behav Res Ther. 2006;44(3):371-394.

7. Nock MK, Prinstein MJ. Contextual features and behavioral functions of self-mutilation among adolescents. J Abnorm Psychol. 2005;114(1):140-146.

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9. Klonsky ED. The functions of deliberate self-injury: a review of the evidence. Clin Psychol Rev. 2007;27(2):226-239.

10. Nock MK. Actions speak louder than words: an elaborated theoretical model of the social functions of self-injury and other harmful behaviors. Appl Prev Psychol. 2008;12(4):159-168.

11. Nock MK, Prinstein MJ. A functional approach to the assessment of self-mutilative behavior. J Consult Clin Psychol. 2004;72(5):885-890.

12. Nock MK, Prinstein MJ. Contextual features and behavioral functions of self-mutilation among adolescents. J Abnorm Psychol. 2005;114(1):140-146.

13. Favazza AR, Rosenthal RJ. Diagnostic issues in self-mutilation. Hosp Community Psychiatry. 1993;44(2):134-140.

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Formerly called self-mutilation, self-injury, or self-harm, nonsuicidal self-injury (NSSI) is the deliberate and direct alteration or destruction of healthy body tissue without suicidal intent; these behaviors range from skin cutting or burning to eye enucleation or amputation of body parts. NSSI must be deliberate, as opposed to accidental or indirect behaviors—such as overdoses or ingesting harmful substances—that cause injury that is uncertain, ambiguous as to course, or invisible (the injuries do not disfigure observable body tissue).¹ NSSI acts are done without an intent to die, although persons who self-harm may have suicidal ideation and passive thoughts of dying.² Persons who repeatedly engage in NSSI and are demoralized over their inability to control it are at risk for suicide attempts.³

NSSI can be classified as nonpathological or pathological.⁴ Culturally sanctioned, nonpathological NSSI consists of body modification practices such as tattoos or piercing. Body modification practices may be a sublimation of pathological NSSI. For a description of nonpathological NSSI, see the Box.⁵ Pathological NSSI typically is a method of emotional regulation. Understanding why patients engage in pathological NSSI and how it is categorized can help guide assessment and treatment.

Box

Body modification: When self-injury is not pathological

Body modification practices and rituals are culturally sanctioned forms of nonsuicidal self-injury (NSSI). Body modification practices include tattooing and piercing earlobes, nipples, and other body parts to accommodate jewelry. Most practices are harmless but when carried to extremes, they may point to underlying neuroses. For some patients, a tattoo or piercing may be psychologically beneficial—eg, to reclaim one’s body after an attack or rape.⁵

Body modification rituals, such as head gashing by Sufi healers, penis cutting during aboriginal coming-of-age ceremonies, and Hindu body piercing to attain spiritual goals, are meaningful activities that reflect the tradition, symbolism, and beliefs of a society. These rituals serve an elemental purpose by correcting or preventing destabilizing conditions that threaten people and communities, such as mental and physical diseases; angry gods, spirits, or ancestors; failure of children to accept adult responsibilities; conflicts (eg, male-female, intergenerational, interclass, intertribal); loosening of clear social role distinctions; loss of group identity; immoral or sinful behaviors; and ecological disasters.

These rituals are effective because participants believe they promote healing, spirituality, and social order. Knowledge about body modification practices and rituals in which NSSI is perceived to be therapeutic opens the door to an understanding of pathological NSSI as a form of self-help behavior and allows clinicians to have a more empathic interaction with patients who self-injure.

Why people engage in NSSI

NSSI is best regarded as a pathological approach to emotional regulation and distress tolerance that provides rapid but temporary relief from disturbing thoughts, feelings, and emotions. For approximately 90% of patients, NSSI decreases symptoms, most commonly untenable anxiety (“It’s like popping a balloon”), depressed mood, racing thoughts, swirling emotions, anger, hallucinations, and flashbacks.^6,7 In some instances, NSSI generates desired feelings and self-stimulation during periods of dissociation, depersonalization, grief, insecurity, loneliness, extreme boredom, self-pity, and alienation.^8,9 NSSI also may signal distress to elicit a caring response from others or provide a means of escape from intolerable social situations.¹⁰Table 1 lists factors associated with NSSI.

Table 1

Factors associated with NSSI

High levels of negative and unpleasant thoughts and feelings^a
Poor communication skills and problem-solving abilities^b
Abuse, maltreatment, hostility, and marked criticism during childhood^c,^d
Under- or over-arousal responses to stress^b
High valuation of NSSI to achieve a desired response^e
Need for self-punishment^a
Modeling behaviors based on exposure to NSSI among peers, on the Internet—ie, postings on YouTube—and in the media^f
NSSI: nonsuicidal self-injury Source: References Deliberto TL, Nock MK. An exploratory study of correlates, onset, and offset of non-suicidal self-injury. Arch Suicide Res. 2008;12(3):219-231. Nock MK, Mendes WB. Physiological arousal, distress tolerance, and social problem-solving deficits among adolescent self-injurers. J Consult Clin Psychol. 2008;76(1):28-38. Weierich MR, Nock MK. Posttraumatic stress symptoms mediate the relation between childhood sexual abuse and nonsuicidal self-injury. J Consult Clin Psychol. 2008;76(1):39-44. Yates TM. The developmental psychopathology of self-injurious behavior: compensatory regulation in posttraumatic adaptation. Clin Psychol Rev. 2004;24(1):35-74. Whitlock JL, Powers JL, Eckenrode J. The virtual cutting edge: the Internet and adolescent self-injury. Dev Psychol. 2006;42(3):407-417. Lewis SP, Heath NL, St Denis JM, et al. The scope of nonsuicidal self-injury on YouTube. Pediatrics. 2011;127(3):e552-e557.

The functional approach

One model of classifying NSSI focuses on the behavioral functions it serves.^11,12 In this model, the most common function of NSSI is removal or escape from an aversive affective or cognitive state (automatic positive reinforcement). Automatic negative reinforcement explains using NSSI to generate feelings—eg, by patients with anhedonia or numbness. NSSI also may be used as a signal of distress to gain attention, access helpful environmental resources (social positive reinforcement), or remove distressing interpersonal demands (social negative reinforcement).