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Non-Suicidal Self-Injury

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Eur Child Adolesc Psychiatry (2011) 20:103–108

DOI 10.1007/s00787-010-0156-y

ORIGINAL CONTRIBUTION

Non-suicidal self-injury
Paul Wilkinson • Ian Goodyer

Received: 1 December 2010 / Accepted: 16 December 2010 / Published online: 11 January 2011
Ó Springer-Verlag 2011

Abstract Self-injury is a relatively common phenomenon Keywords Non-suicidal self-injury  Adolescence 


in adolescence. Often there is no suicidal intent; rather, the Suicide  Depression  Borderline personality disorder
action is used for one or more reasons that relate to
reducing distressing affect, inflicting self-punishment and/ Abbreviations
or signalling personal distress to important others. Non- NSSI Non-suicidal self-injury
suicidal self-injury (NSSI) is both deliberate and contains DSM-5 5th Edition of the Diagnostic and Statistical
no desire to die and therefore aetiology is likely to be at Manual of Mental Disorders
least partly different to suicidal behaviour per se. Inter-
estingly, NSSI is associated with subsequent suicide
attempts suggesting that these behaviours and their related
psychology may lie on the same risk trajectory. NSSI
Introduction
neither appears in DSM-IV or ICD 10 as a disorder nor
does it constitute a component of any current anxious or
Seven to 14% of adolescents deliberately injure themselves
depressive syndrome. This lack of nosological recognition
at least once [1]. The most commonly reported behaviour is
coupled with clear psychopathological importance is to be
self-cutting, which is somewhat more frequent in females
recognised in the 5th edition of the Diagnostic and Statis-
than males. In some cases, self-harm is with the explicit
tical Manual of Mental Disorders (DSM-5), with NSSI
intention of trying to end their life. For the majority,
being classified as a syndrome in its own right. We agree
however, there is no suicidal intent. The most common
that this is appropriate and is likely to have several positive
reason for non-suicidal self-injury (NSSI) is to relieve
consequences including: (1) improving communication
intense distressing affect (e.g. sadness, guilt, flashbacks,
between professionals and patients; (2) informing treat-
and depersonalisation) by the use of sharp physical pain,
ment and management decisions; (3) increasing research
which can distract the sufferer from their unbearable feel-
into the nature, course and outcome of NSSI. We agree
ings [2]. Other reasons include: self-punishment, which the
with the proposed DSM-5 diagnostic criteria, although
adolescent sees as ‘deserved’; to gain attention so that other
believe the impairment criterion would be better phrased if
people can see their distress; to make other people feel
it stated that self-injury is associated with, rather than
guilty and change their behaviour; to fit in socially with
causal for, intense distress.
peers who self-injure. While NSSI often results in short-
term relief from distress [2], it frequently leads to longer-
term negative consequences. Emotionally, it can evoke
more complex feelings of guilt and shame towards the self
P. Wilkinson (&)  I. Goodyer [2]. Socially, it can lead to teasing from peers and shock
Developmental Psychiatry Section, University of Cambridge, from parents who may then become over-protective.
Douglas House, 18b Trumpington Road, Physically, it can lead to infection and scarring. Despite
Cambridge CB2 8AH, UK awareness of the negative consequences when in a calm
e-mail: pow12@cam.ac.uk

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104 Eur Child Adolesc Psychiatry (2011) 20:103–108

mood, it can be difficult to resist the strong urge to self- behaviourally disturbed children and adolescents. It greatly
harm when angry and/or depressive feelings are intense, aids communication when all psychiatric diagnoses are
especially when self-injury has been rewarded in the past listed as a part of inter-professional communication,
by reduction of distress. It is a problem, and adolescents especially if a multi-axial format is used. It also helps
often want help in stopping it. clinicians to think of all the problems that need addressing.
But, is NSSI enough of a problem to warrant a diag- Elevating NSSI to a full diagnostic category will increase
nostic label of its own? NSSI has been proposed as a new the visibility of this abnormal behaviour, ensuring that it is
diagnostic category within DSM-5 [3], see ‘‘Appendix’’. recorded within a clinical formulation, thereby giving
This review will first discuss whether we think it appro- greater clarity to the range of problems suffered by an
priate to include NSSI as a separate DSM-5 psychiatric adolescent. Of course, this will only be useful if the pres-
diagnosis. It will then discuss the proposed DSM-5 diag- ence of NSSI has implication in terms of treatment and
nostic criteria. prognosis. We shall argue below that this is indeed the
case.

Should NSSI be included within DSM-5? Reduced problems from lack of diagnostic specificity
for NSSI
In some cases of adolescent self-injury, it is difficult to
distinguish between suicidal and non-suicidal intent. But in The only DSM-IV psychiatric diagnosis which includes
many cases, patients are clear that there was no desire to die NSSI as a criterion is BPD (301.83) [4]. This can lead some
associated with the act. Therefore, it is feasible to phe- clinicians to make an automatic assumption that a patient
nomenologically separate suicidal from non-suicidal self- who engages in NSSI may have this condition (BPD). This
injury. That this adverse behaviour is clinically significant is not appropriate for multiple reasons. First, many clini-
over the life course with origins in childhood and adoles- cians believe that a diagnosis of personality disorder should
cence is suggested by its inclusion as an entry criterion for not be given to a child or younger adolescent, whose per-
borderline personality disorder (BPD) in adult life. To date, sonality is still developing [5]. Second, NSSI is often
there is no psychopathological significance given to this present in patients with psychiatric disorders, including
behaviour in younger people, despite research findings that depression, post-traumatic stress disorder, other anxiety
in adolescent groups the condition is prevalent, impairing disorders, conduct disorder and substance misuse disorders
and under-recognised [1]. Furthermore when present, there [6, 7]. Third, NSSI may be present and may be a problem
is nowhere in the current classification of axis I emotional in a patient who does not meet diagnostic criteria for a
disorders in young people to record this behaviour as a mental illness or personality disorder. It is clearly crucial to
symptom. While NSSI is a symptom of BPD [4], this is make the correct diagnosis, so that appropriate treatment is
generally seen as an inappropriate diagnosis for children and given. Assigning a specific diagnostic category to NSSI
younger adolescents, whose personalities are still develop- makes it more likely that clinicians will consider treatment
ing. This implies by default that mental health professionals and management in more flexible ways than may occur if
do not need to consider this behaviour as abnormal or even the assumption is made that NSSI is simply indexing a
non–normative. We believe that the combination of the BPD. Third, an assumption of BPD may lead to a bias in
feeling of intense negative distress (often characterised by clinician perception of an adolescent with mental health
anger and/or sadness) and self-harm, together with their difficulties. We know little about BPD components from a
adverse consequences, is both necessarily within the clinical developmental context and there is a risk of translating
domain and of sufficient importance to warrant a separate down to the adolescent years information about treatment
diagnostic category in young people. and management generated from an older and putatively
We believe that the new proposed category of NSSI will different clinical population.
be helpful for several reasons: to improve communication;
to reduce problems from the lack of diagnostic specificity Improved provision of treatment
for NSSI; to improve provision of treatment for adolescents
who engage in NSSI; improve research on aetiology, NSSI may be present with a psychiatric disorder, but for
treatment and outcome. These will be detailed below. many who engage in this behaviour, there is no associated
set of signs and symptoms to warrant a psychiatric diag-
Improved communication nosis. In the absence of a mood or behavioural disorder (or
personality disorder in older adolescents), there is currently
Concurrent as well as sequential co-morbidity of psychi- no place for recording this behaviour. Nevertheless, ado-
atric diagnoses is common in mentally unwell and lescents who engage in NSSI are deserving of treatment:

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Eur Child Adolesc Psychiatry (2011) 20:103–108 105

both to reduce the distress and impairment from their but suicide attempts are the strongest risk factor for future
negative emotional state that leads them to self-injure, and suicide in adolescents [12]. Therefore, NSSI is likely to be
to reduce the harms from the NSSI. In health care systems a predictor of completed suicide adding to the evidence
where funding may be dependent on diagnostic labels for that the behaviour is clinically important.
payment, a distressed self-harming adolescent will not The association of NSSI with future suicide risk means
receive treatment unless they are labelled with an ‘incor- that adolescents who engage in NSSI without any apparent
rect’ diagnosis for their presenting complaint. It is not emotional or behavioural disorder are properly assessed for
known if this is currently occurring. The addition of NSSI suicide risk. Furthermore adolescents with other known
to DSM-5 will improve the chances of assessment, treat- psychiatric risks factors for suicide, such as existing clin-
ment and management being given in the absence of other ical depression, substance misuse and conduct disorder,
emotional conditions. should be assessed for a current and lifetime history of
NSSI [12]. Finally, NSSI may well have prognostic sig-
NSSI has prognostic implications nificance for the development of BPD in young adult life
and earlier recognition and treatment may reduce the risk
NSSI in itself has negative emotional, physical and social of developing this pervasive and disabling condition.
consequences. However, it is also associated with the more
worrying behaviour of suicide attempts. Cross-sectional Specific treatment for NSSI
studies have demonstrated that adolescents who engage in
NSSI are more likely to make suicide attempts than those The presence of short- and long-term adverse consequences
who do not engage in NSSI [8]. Longitudinal research has of NSSI means that treatment needs to be considered in its
demonstrated that a history of NSSI before the index sui- own right and not just if the adolescent meets criteria for a
cide attempt is more likely in adolescent in-patients who mental illness or behavioural disorder. Successful treat-
have attempted suicide than those who have suicidal ide- ment of existing psychiatric disorders may mean that NSSI
ation but not suicide attempts [9]. Data from one of our stops, but this does not always happen. Assigning NSSI as
own studies (a secondary analysis of the ADAPT data) a separate disorder is likely to increase the chance that
demonstrate that the strongest predictor of a suicide specific treatment will be offered. Once this occurs, there is
attempt over a 6 months follow-up in depressed adoles- a greater chance than hitherto that effective treatments will
cents receiving treatment under randomized controlled trial be developed. Sadly, research that has investigated strate-
conditions is NSSI, but not suicide attempts, at baseline gies to reduce self-injury (whether separated into suicidal
[10]. This significant association holds when controlling and non-suicidal self-injury or whether these two catego-
for other potential confounders at entry, including suici- ries were combined) has failed to demonstrate efficacy or
dality, gender, severity of depression and current family effectiveness more than control treatments. Dialectical-
dysfunction. A large follow-up study of people who pre- behaviour therapy has been demonstrated to be more
sented to hospital with self-harm demonstrated that com- effective than treatment as usual at reducing suicidal and
pleted suicide is predicted by both NSSI and suicide NSSI in adults. There have been no randomized controlled
attempt as the index presentation, with no difference in the trials of DBT in adolescents and the non-randomized pilot
likelihood of future suicide between baseline suicidal and studies that have taken place have not demonstrated any
non-suicidal self-harm [11]. This longitudinal research difference between DBT and treatment as usual [13].
suggests that NSSI is a risk factor for future suicide Despite encouraging findings from an earlier study, a
attempts. As only a minority of people who have suicidal specific group intervention (using CBT and DBT tech-
ideation attempt suicide; it may be that the presence of niques) led to higher self-harm rates than treatment as usual
NSSI is a marker for crossing the boundary between ideas in a study of self-injuring adolescents [14]. Two random-
and suicidal acts. From the neuropsychological perspec- ized controlled trials have demonstrated that adding cog-
tive, it may be that it represents a behavioural outcome of nitive-behavioural therapy (CBT) to selective serotonin
impaired behavioural inhibition at a time of an acute rise in reuptake inhibitor (SSRI) antidepressants leads to a sig-
negative emotional tone (fear, anger, irritability or sad- nificant additional reduction in depressive symptoms. In
ness), increasing impulsivity for and decreasing regulatory contrast neither study demonstrated that adding CBT to
factors against adverse self-harming behaviour [6]. Once SSRI led to a significant additional reduction in self-injury,
NSSI is established, it is possible that recurrence habituates whether suicidal and NSSI were classified together [15] or
people to the pain from self-harm suggesting that they are separately [16].
insensitive to punishing outcomes and/or more directed to The lack of evidence for effective treatments for NSSI
the acute rewards [6]. Most studies to date have not been in young people demonstrates the need to develop treat-
large enough to determine predictors for completed suicide ments that are more specific than assuming indirect

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response via treating the primary psychiatric condition; and appropriately and explicitly labels the behaviour as non-
subsequently test these in large, adequately powered suicidal. The term self-mutilation implies an extreme
studies. degree of damage, whereas the usual behaviour is milder
(e.g. skin scratching with a blunt implement). Self-harm is
Improved research sometimes used, but some people include behaviours such
as gambling and substance use within this. As detailed
Although there is an abundance of descriptive research on below, we do not think such a broad definition should be
adolescent self-injury, most fails to distinguish suicidal used, and the use of the term self-injury makes it clear that
from non-suicidal behaviours. From the above, we have this behaviour is just referring to physically injuring
asserted that the two are not the same thing and they may oneself.
have different as well as shared aetiological components.
For example there are common aetiological factors, which Criterion A: definition of self-injury
increase the risk of both behaviours: depression can contain
intensely distressing affect, which may be relieved by We believe that criterion A is appropriate: the self-injury
NSSI, or a wish to be dead; the combination of impulsivity needs to be significant, is explicitly non-suicidal and a
and a lack of alternative coping strategies may lead to a threshold of at least 5 days over 1 year limits this to people
mentally ill young person to cross the threshold between who have truly repetitive NSSI, rather than just experi-
thinking of self-injury and carrying out the act; a childhood menting on a small number of occasions. The proposers of
history of abuse can lead to both suicidality and NSSI [2]. this threshold for DSM-5 state that there is not good
Some evidence is also emerging for distinct aetiologies: research that correlates frequency of self-injury with an
adolescents who only attempt suicide are more likely to external validator [3]; however, 5 days is around the
have a concurrent clinical disorder of depression or PTSD middle of the accepted range for the definition of NSSI in
than those who only engage in NSSI; those who only most studies. We agree that it is reasonable to go with the
engage in NSSI are more likely to have features of BPD consensus view from extant literature in the absence of
[7]. In our ADAPT study, suicide attempts but not NSSI evidence for criterion validity.
were predicted by family problems; whereas, NSSI but not Some people have a looser definition of self-harm,
suicide attempts were predicted by concurrent anxiety including risky behaviours, such as gambling and sub-
disorders and female gender [10]. stance misuse. We agree with the proposed definition that
It is important that future research distinguishes the two only includes self-injury that has the explicit aim of
forms of self-injury. This will provide more information on injuring the self. While there are multiple reasons for such
the prevalences of these behaviours, thus revealing the self-injury, the person doing this is fully aware that this
public health implications and treatment needs. A more injury will happen and wants the injury to happen. On the
detailed study of mechanisms of self-injury and comparing other hand, behaviours such as gambling and substance
these with suicide will ensue, including the neural systems misuse have more complex motivations. In particular, they
that may underpin each or both. Such mechanistic studies are often motivated by the short-term pursuit of potentially
would provide more information than is currently present pleasurable rewards or insensitivity to losses, and any harm
on the aetiologies of the two behaviours and is likely to to the self is incidental, not sought or intended. Behaviours
inform the design of specific treatments. Most importantly, such as body piercing and tattooing are normally carried
it should lead to treatment studies testing specific inter- out to improve physical appearance—the pain involved is
ventions for NSSI in the presence and the absence of other normally an unwanted rather than a desired side-effect. It is
psychopathologies. important that research focuses on one homogenous
We believe that the inclusion of NSSI in DSM-5 will behaviour and we believe that NSSI is a reasonable
encourage research specifically on NSSI, rather than homogenous behaviour that is different to other types of
including it within the broader category of self-injury. ‘self-harm’.

Criterion B: associated features


Commentary on proposed DSM-5 criteria for NSSI
People who engage in pathological NSSI have associated
The proposed name of the condition: negative thoughts and feelings that lead to the NSSI. It is
non-suicidal self-injury appropriate that this is reflected in the diagnostic criteria,
which here include both the negative feelings/thoughts
We think this to be an appropriate name that is consistent (and use of NSSI to relieve these) and the degree of pre-
with the term used in a lot of the literature [6]. It occupation and urge. A threshold of two of these criteria

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Eur Child Adolesc Psychiatry (2011) 20:103–108 107

makes it likely that all people who engage in truly patho- harm. The absence of suicidal intent is either reported
logical NSSI will meet such criteria. by the patient or can be inferred by frequent use of
methods that the patient knows, by experience, not to
Criterion C: impairment criterion have lethal potential. (When uncertain, code with
NOS 2.) The behaviour is not of a common and trivial
It is essential to have a functional impairment criterion for nature, such as picking at a wound or nail biting.
most diagnoses to demonstrate that somebody’s life is B. The intentional injury is associated with at least two of
adversely affected through distress or functional impair- the following:
ment. Self-injury that is significant is associated with short-
1. Negative feelings or thoughts, such as depression,
and/or long-term adverse consequences (physical, social
anxiety, tension, anger, generalised distress, or
and/or emotional). It is usually associated with significant
self-criticism, occurring in the period immediately
distress—before and/or after the self-injury. It may be more
prior to the self-injurious act.
appropriate for the criterion to state ‘The behaviour and its
2. Prior to engaging in the act, a period of preoc-
consequences are associated with clinically significant
cupation with the intended behaviour that is
distress or impairment’ rather than using the word cause, to
difficult to resist.
reflect the fact that in some cases, the intense distress may
3. The urge to engage in self-injury occurs fre-
immediately precede, and trigger, the self-injury, and are
quently, although it might not be acted upon.
not caused by it.
4. The activity is engaged in with a purpose; this
might be relief from a negative feeling/cognitive
Criterion D: exclusion criteria
state or interpersonal difficulty or induction of a
positive feeling state. The patient anticipates these
We agree that it is important that for NSSI to be diagnosed
will occur either during or immediately following
there must be clear intent to self-injure. Therefore, it is not
the self-injury.
appropriate to diagnose it when intent may be clouded by
intoxication, delirium or psychosis. We also agree that C. The behaviour and its consequences cause clinically
conditions with stereotyped behaviour that may include significant distress or impairment in interpersonal,
self-injury should be excluded. academic, or other important areas of functioning.
D. The behaviour does not occur exclusively during
states of psychosis, delirium, or intoxication. In
Conclusions individuals with a developmental disorder, the behav-
iour is not part of a pattern of repetitive stereotopies.
NSSI is common in adolescents. It is associated with The behaviour cannot be accounted for by another
intense negative thoughts and feelings and negative emo- mental or medical disorder (i.e. psychotic disorder,
tional, physical and social consequences. The behaviour pervasive developmental disorder, mental retardation,
may occur in isolation or in association with one of a Lesch-Nyhan syndrome).
number of specific psychiatric syndromes. We believe that
NSSI warrants a diagnostic category in its own right and
agree with inclusion of this in DSM 5. References

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