Nonsuicidal self-injury is a self-inflicted act that causes pain or superficial damage but is not intended to cause death.
Nonsuicidal self-injury generally refers to a behavior rather than a disorder. It can, however, be a feature of a wide variety of psychiatric disorders, such as posttraumatic stress disorder, dissociative identity disorder, eating disorders, alcohol and substance use disorders, borderline personality disorder, antisocial personality disorder, excoriation disorder, and autism.
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 completion 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 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 early adolescence. Rates from general population studies are similar between men and women. The natural history is unclear, but the behavior appears to decrease after young adulthood (1). 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
A way to reduce tension or negative feelings
A way to resolve interpersonal difficulties
Self-punishment for perceived faults
A plea for help
Some patients view the self-injury as a positive activity and thus tend not to seek or accept counseling.
General reference
1. Klonsky ED, Victor SE, Saffer BY. Nonsuicidal self-injury: What we know, and what we need to know. Can J Psych. 59(11):565-568, 2014. doi: 10.1177/070674371405901101
Diagnosis of Nonsuicidal Self-Injury
Psychiatric assessment
Exclusion of suicidal behavior
Assessment of self-injury
Nonsuicidal self-injury is not a formally recognized disorder in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition, Text Revision (DSM-5-TR); instead, it is listed as an "Other condition that may be a focus of clinical attention." It is also listed as a "Condition for further study," or proposed disorder, with full diagnostic criteria.
The proposed diagnostic criteria for nonsuicidal self-injury disorder include the following:
Intentional self-inflicted damage, without suicidal intent, on 5 or more days
Expectation of relief from negative feeling/cognitive state or creation of a positive feeling, or resolution of an interpersonal problem
Association with interpersonal difficulties or negative thoughts/feelings
Not socially sanctioned; not restricted to nail biting or picking a scab
Causes significant dysfunction and/or distress
Not better explained by another psychiatric condition, a general medical condition, or substance use/withdrawal
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 clinicians plan treatment. Clinicians 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 of nonsuicidal self-injury should include the following:
Determining what type of self-injury and how many types of self-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 of Nonsuicidal Self-Injury
Certain forms of psychotherapy (eg, cognitive-behavioral therapy, dialectical behavioral therapy, emotion-regulation group therapy)
Treatment of coexisting disorders
Cognitive-behavioral therapy is typically done as outpatient, individual therapy, but it can also be done in groups in an inpatient setting. Improvement occurs by helping people change the ways they respond to their automatic thoughts, and unlinking negative thought-behavior-mood patterns (1).
Dialectical behavioral therapy involves individual and group therapy for at least 1 year, and phone coaching between sessions (2, 3). 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) (1).
Emotion-regulation group therapy 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. Emotion-regulation group therapy helps patients accept negative emotions as part of life and thus not to respond to such emotions so intensely and impulsively (1).
No medications have been approved for the treatment of nonsuicidal self-injury. However, naltrexone and certain second-generation antipsychotics have been effective in some patients (No medications have been approved for the treatment of nonsuicidal self-injury. However, naltrexone and certain second-generation antipsychotics have been effective in some patients (1).
Coexisting psychiatric disorders (eg, depression, eating disorders, substance use disorders, borderline personality disorder, bipolar disorder) should be treated appropriately. Patients should be referred to an appropriate clinician as needed.
Treatment references
1. Turner BJ, Austin SB, Chapman AL. Treating nonsuicidal self-injury: a systematic review of psychological and pharmacological interventions. Can J Psychiatry. 2014 Nov;59(11):576-85. doi: 10.1177/070674371405901103
2. Storebø OJ, Stoffers-Winterling JM, Völlm BA, et al. Psychological therapies for people with borderline personality disorder. Cochrane Database Syst Rev. 2020;5(5):CD012955. Published 2020 May 4. doi:10.1002/14651858.CD012955.pub2
3. Leichsenring F, Heim N, Leweke F, Spitzer C, Steinert C, Kernberg OF. Borderline Personality Disorder: A Review. JAMA. 2023;329(8):670-679. doi:10.1001/jama.2023.0589
