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?
Also known as self-injury and self-harm, nonsuicidal 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 be a cultural component to the self-injury. While NSSI acts are done without suicidal intention, the person often is also experiencing suicidal thoughts or vague thoughts of dying.
NSSI can be classified as non-pathological or pathological. Non-pathological NSSI is culturally sanctioned, and includes acts like 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 be used to provide self-stimulation during times of dissociation and depersonalization. Pathological NSSI can be used to signal distress and elicit a caring response from others. Factors associated with pathological NSSI include: depression and anxiety; poor communication skills and problem-solving abilities; abuse or maltreatment during childhood or other history of trauma; and under- or over-arousal responses to stress.
There are two different ways to classify pathological NSSI: one is a functional approach and the other is a medical approach. The functional approach focuses on the function that the behavior serves. For some people who engage in NSSI, the function it serves is as an autonomic positive reinforcement (removal or escape from an aversive affective or cognitive state). For others, 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 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 worry, 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 exist 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 includes psychotherapy. Dialectical behavioral therapy (DBT) is an important component of treatment for impulsive NSSI. The goal of treatment is to help patients tolerate the intolerable feelings that lead to NSSI and to find appropriate replacement behaviors. Behavioral therapy can be an important component of treatment for stereotypic NSSI. In addition, while there is no medication that treats NSSI directly, psychotropic medication to address the underlying psychiatric disorder, whether it be a psychotic disorder, anxiety disorder, or mood disorder, can also play an important role.
It can be challenging to ask patients about NSSI in the primary care setting. There can be a lot of stigma and shame associated with NSSI. It is important for the primary care provider to ask open-ended questions and lead into specific questions to elicit specific information to understand the severity of the NSSI. SmartCare PC2 can help primary care providers provide appropriate referrals for patients engaging in NSSI.
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.