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* This is the Professional Version. *

Nonsuicidal Self-Injury (NSSI)

By Paula J. Clayton, MD, American Foundation for Suicide Prevention

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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 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 a visible and/or accessible area (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, and prevalence is more evenly distributed between the sexes than that of suicidal behavior. The natural history is unclear, but the behavior appears to decrease after young adulthood.

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, or 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, eating disorders, and substance abuse.

Diagnosis

  • 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 should include the following:

  • Determining what type of injury and how many types of 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

  • Sometimes certain forms of psychotherapy

  • Treatment of coexisting disorders

The following psychotherapies 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 yr. ERGT is done in a 14-wk group setting.

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 abuse, borderline personality disorder) should be treated appropriately. Patients should be referred to an appropriate health care practitioner as needed.

Follow-up appointments should be scheduled.

* This is the Professional Version. *