Understanding Nonsuicidal Self-Injury
By: Ashley L. Peterson
Tags: Self Injury, Mental Illness, Self Harm, Mental Health, Cutting

Understanding Nonsuicidal Self-Injury

Photo by Uriel SC on Unsplash

Nonsuicidal self-injury (NSSI) is a fancy way of saying self-harm behaviour that differentiates it from suicidality. Cutting and burning are the most common methods, but there are a variety of other methods people use, including scratching, burning, and hitting.

The onset of NSSI on average is between ages 11 and 15, and it tends to be more severe and prolonged if it starts when people are under 12 years old. About 15–20% of adolescents self-injure at some point. It’s difficult to say if this has changed over time because it just hasn’t been studied for all that long, so there isn’t historical data. There’s some indication that there’s an element of contagion in the spread of NSSI through populations, but it’s unclear what might be driving that process.

A common misconception is that self-injury is a female issue, but NSSI is only slightly more common in females than males.

Females tend to start younger and self-injure longer. In terms of method, females are more likely to cut, while males are more likely to punch/hit or burn themselves. There’s an elevated risk in transgender and bisexual youth and young adults. Being homosexual doesn’t appear to have a large impact on risk, but the elevated risk among bisexuals has been consistently demonstrated, although the reason is unclear.

People who self-injure tend to be more sensitive to interpersonal stress/conflict and have difficulties with emotion regulation. Self-directing negative emotions and self-criticism can make people more susceptible.

Self-injury often occurs alongside other mental disorders, including borderline personality disorder, eating disorders, substance use disorders, PTSD, depression, and anxiety disorders. Around 15–20% of adolescents who engage in NSSI don’t have any diagnosable mental disorder.

There can be many reasons behind self-injury. It’s often a means of relieving inner emotional pain, but it can also be a way of creating physical pain to counteract inner numbness. It can be a way of channelling anger at the self or self-punishment. It’s sometimes used for interpersonal reasons, such as conveying a message to others, but that’s much less common.

Suicide isn’t typically on people’s minds while self-injuring, but they are at increased risk of suicide overall, and often have comorbid conditions that also increase their risk.

With NSSI, there appears to be an increase in the risk of suicidality up until around 50 lifetime self-injury episodes, at which point the risk levels off and then starts to drop closer to population norms. When people with a history of NSSI are suicidal, there may be less reluctance to try more lethal methods because of previous self-injury.

NSSI doesn’t currently have a diagnosis attached to it, although it’s been included in the DSM-5 as a proposed disorder to be studied for future inclusion. While it’s not classified as an addiction, it does have addictive elements to it. Self-injury stimulates the release of endogenous opioids, and tolerance can develop to this, so a greater degree of injury is needed to produce the same opioid release.

Treatment involves addressing any co-occurring disorders. Naltrexone (which may help by blocking the action of endogenous opioids) or atypical antipsychotics are sometimes helpful. In terms of therapy, DBT can be useful, as can emotional regulation group therapy, which is a 14-week group that focuses on awareness and management of emotions. CBT, mindfulness-focused therapies, and family therapy may also be helpful.

People like to get judgy, and nonsuicidal self-injury is the target of a lot of misconceptions and judgments. Attention-seeking is a popular label, and one of the misconceptions is that only people with borderline personality disorder self-harm. As with anything else that’s stigmatized, the stigma certainly doesn’t help people get the help they need.