Also known as self-injury and self-harm, non-suicidal self-injury (NSSI) refers to the deliberate and direct alteration or destruction of healthy body tissue without suicidal intent. This can range from skin cutting or burning to amputation of body parts. There can also be a significant cultural component to the self-injury. While NSSI acts are done without suicidal intention, the person may also be experiencing suicidal thoughts or vague thoughts of dying, so these issues should be openly addressed.
NSSI can be classified as non-pathological or pathological. Non-pathological NSSI is culturally sanctioned, and includes acts such as piercings and tattoos. Pathological NSSI is used by some as a method for emotional regulation to try to provide rapid but temporary relief from disturbing thoughts, feelings, and emotions. Patients who engage in NSSI will describe that the physical pain helps to numb the emotional pain. Pathological NSSI can also be used to provide self-stimulation during times of dissociation and depersonalization. Pathological NSSI can further be used to signal distress and elicit a caring response from others. Factors associated with pathological NSSI include: a history of trauma, high levels of unpleasant thoughts or feelings; poor communication skills and problem-solving abilities; abuse or maltreatment during childhood; and under- or over-arousal responses to stress.
There are different ways to classify pathological NSSI: a functional approach and a medical approach. The functional approach focuses on the function that the behavior serves. For most people who engage in NSSI, the function served is as an autonomic positive reinforcement (removal or escape from an aversive affective or cognitive state). For some, NSSI functions as an autonomic negative reinforcement (to generate feelings when one feels dissociated or numb). NSSI can serve as a social positive reinforcement (as a signal of distress to gain attention) or as a social negative reinforcement (to escape from intolerable social situations).
In the medical approach, pathological NSSI falls into 4 major categories, which are associated with specific psychiatric disorders. The 4 categories are: major, stereotypic, compulsive and impulsive. Major NSSI includes infrequent acts that destroy significant body tissue. The majority of these occur during psychotic states and the explanation provided by the patient defies logic and demonstrates delusional thinking. Stereotypic NSSI is repetitive and can have a rhythmic pattern, and includes acts like head banging, biting skin and face or head slapping. It is most commonly seen with intellectual disabilities and autism spectrum disorders. Compulsive NSSI, seen in certain anxiety disorders, includes excessive nail biting, hair pulling, and skin picking.
Impulsive NSSI consists of acts like skin cutting or burning, sticking pins under the skin, and interfering in wound healing. It is more common in females and typically starts during the teen years. One or two isolated incidents of minor impulsive NSSI may not be cause to for intensive intervention, but it is concerning if it develops into a repetitive, addictive pattern. Many patients with borderline personality disorder engage in impulsive NSSI but not everyone with impulsive NSSI has borderline personality disorder. Impulsive NSSI can occur in patients with mood disorders, anxiety disorders and psychotic disorders, as well as other personality disorders. Other disorders in which impulsivity is common, like bulimia or substance abuse, may alternate or coexist with NSSI.
The first line treatment for NSSI is psychotherapy. Dialectical behavioral therapy (DBT), which seeks to identify the emotional and thought triggers that lead to the behavior, is an important component of treatment for impulsive NSSI. More traditional behavioral therapies can be an important component of treatment for stereotypic NSSI, where the patient’s cognitive skill may be more limited. In addition, while there is no medication that treats NSSI directly, psychotropic medication addressing an underlying psychiatric disorder, whether it be a psychotic disorder, an anxiety disorder, or a mood disorder, is also important.
NSSI will often be first identified in patients seen in the primary care setting. Because there can be a lot of stigma and shame associated for the NSSI patient and as providers may also react judgmentally, it is important for the primary care provider to be able to conduct an assessment when a patient has engaged in NSSI with sensitivity to help determine appropriate referrals and the course of treatment.
15yo girl with symptoms of depression and slightly elevated PHQ-9 who is engaging in non-suicidal self-injury. She denies active SI and is currently doing well academically and socially with family and peers. The question that was posed is about treatment – should medication automatically be considered because of the self harm? What is the treatment of choice for the self-harm?
Given that the other symptoms of depression are mild and there is no current impairment at school or with relationships and no current SI, it would be okay to start with therapy with focus on the NSSI and reassess over time if medication could be helpful if symptoms do not improve with therapy alone or worsen over time.
Nonsuicidal self-injury: how categorization guides treatment. Armando R. Favazza, MD. Current Psychiatry; March 2012