Nonsuicidal Self-Injury (NSSI)
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
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
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 abuse, and autism.
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:
Assessment of nonsuicidal self-injury 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
The following cognitive-behavioral therapies may be useful for treating nonsuicidal self-injury:
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 abuse, 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.