Non-suicidal self injury (NSSI) is the professional name for a number of forms of self-injury. Self-injury is a very common mental and physical health issue affecting many populations, but especially young people and trauma survivors.
Types of self-injury include:
- Cutting
- Embedding objects under the skin
- Biting
- Scratching
- Skin-carving
- Hitting
- Head banging
- Interfering with wound healing
Research by Catledge, Scharer, & Fuller (2012) shows that people who self-injure tend to use multiple methods of self-injuring.
Non-suicidal self injury clearly differentiates these actions from those with suicidal attempts but previous terminology including self-harm and deliberate self-harm (DSH) was less clear on this and so they are not the preferred terms.
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Prevalence of Non-Suicidal Self Injury
The prevalence of non-suicidal self injury is estimated at approximately 6% of all American adults (Muehlenkamp, Claes, Havertape, & Plener, 2012). On the ONTX service, approximately 20% of the mental health issues reported by visitors involve non-suicidal self injury. (MacDonald, 2016)
Females are slightly more likely to self-injure than males. (Hawton, 2002)
Causes of Non-Suicidal Self Injury
There are a variety of reasons that people choose to engage in non-suicidal self-injury. The following list is based on the outcomes listed in Rodav, Levy & Hamdan (2014):
- Bonding with others
- Communicate distress
- Dissociation
- Flashbacks or traumatic memories
- Provide an internal sense of control
- Reduce/eliminate negative emotions
- Seek support from others
- Self-punishment
- Suicidal thoughts
- To feel something while numb
Hawton, et. al. (2002) conducted a survey of English adolescents and found differing risk factors for self-injury in males and females. Males were more likely to self-injure if they had suicidal behaviour in friends or family members, used drugs or had lower self-esteem. Females were more likely to self-injure if friends or family members had self-injured, if they used drugs, were impulsive, or had depression, anxiety or low self-esteem.
Impact of Non-Suicidal Self Injury
Non-suicidal self injury has been associated with a number of negative impacts, most notably an increase in suicidal behaviour (Halicka & Kiejna, 2015). Often-times people with borderline personality will have a comorbid diagnosis of non-suicidal self injury; people holding both diagnoses tend to engage in more severe and more frequent self-harm (Turner, et. al., 2015)
Self-injury can decrease self-esteem and cause individuals difficulty in interpersonal relationships, employment and other areas of their life.
Assessing Non-Suicidal Self Injury
There are a number of assessment tools used to assess self injury including the Non-Suicidal Self Injury Assessment Tool (NSSI-AT) by Whitlock, Exner-Cortens & Purington (2007), the Self-Harm Inventory (Sansone & Sansone, 2010) or the Deliberate Self-Harm Inventory by Gratz (2010).
Treatment of Non-Suicidal Self Injury
There are a variety of suggested treatments for non-suicidal self injury. Treatments that have shown themselves effective according to Gonzales (2013) include:
Cognitive Behaviour Therapy (CBT). CBT focuses on examining your thoughts, feelings and beliefs when you feel like self-injuring to help you figure out the trigger points and automatic thoughts leading to self-harm. You can then perform thought-stopping activities and coping strategies (see below) to help you cope. CBT was found to be as effective as treatment-as-usual.
Dialectical Behaviour Therapy (DBT). DBT is an extension of CBT that was originally developed to help individuals with borderline personality disorder (BPD), also called emotional dysregulation disorder to cope. DBT extends CBT by including mindfulness, meditation and other activities designed to replace thought stopping. DBT was found to be as effective as treatment-as-usual.
Therapeutic and Psychosocial Assessment. Therapeutic and psychosocial assessments are tools that can be used by mental health clinicians or ER physicians to help understand when and why the person cuts. Therapeutic assessments were shown to increase the rate of followups while psychosocial assessments were shown to decrease the incidence of future self-harm.
Making Meaning. Making meaning refers to strategies to determine what self-injury means for that particular person. Each person who cuts, burns or embeds gets something out of that particular activity, and knowing more about what it is. Making meaning was identified as being helpful by clients, though there is little research evidence confirming this.
Coping Strategies
In crisis situations or where people feel like they’re not going to be able to keep themselves from self-injuring, it’s important that they have a variety of coping strategies in mind. Coping strategies must be interpreted based on the frame of reference of the self-injuring person. What do they get out of the activity?
Examples of some coping strategies based on what you’re feeling right now are here. Additional strategies may be found here and here.
Feel Pain
- Eat a hot pepper
- Hold ice in your hand
- Snap a rubber band
- Squeeze a stress ball
- Exercise vigorously
Reduce Negative Emotions
- Listen to emotional music
- Write a letter with your feelings written down
- Journal/diary
- Draw, paint or scribble a picture
Comforting yourself
- Take a bath or shower
- Spend time with a beloved pet
- Listen to calming music
- Give yourself a massage
- Drink some tea or another calming beverage
Bibliography
Catledge, C.K., Scharer, K., Fuller, S. (2012) Assessment and identification of deliberate self-harm in adolescents and young adults. Journal of Nurse Practitioner. 8(4)299–305.
Gratz, K.L. (2010) Measurement of deliberate self-harm: preliminary data on the deliberate self-harm inventory. Journal of Psychopathological Behaviour. 23:253–263
Gonzales, A.H. & Bergstrom, L. (2013) Adolescent Non-Suicidal Self-Injury (NSSI) Interventions. Journal of Child and Adolescent Psychiatric Nursing. 124-130. doi: 10.1111/jcap.12035
Halicka, J., & Kiejna, A. (2015). Differences between suicide and non-suicidal self-harm behaviours: a literary review. Archives Of Psychiatry & Psychotherapy, 17(3), 59-63. doi:10.12740/APP/58953
Hawton, K., Rodham, K., Evans, E., Weatherall, R. (2002) Deliberate self harm in adolescents: self report survey in schools in England. BMJ. 325:1207-11
MacDonald, D.K. (2016) ONTX Program Tracking Report, Unpublished raw data.
Muehlenkamp J.J., Claes, L., Havertape, L. & Plener, P.L. (2012) International prevalence of adolescent non-suicidal self-injury and deliberate self-harm. Child and Adolescent Psychiatry and Mental Health. 6(10). doi: 10.1186/1753-2000-6-10.
Rodav, O., Levy, S., & Hamdan, S. (2014). Original article: Clinical characteristics and functions of non-suicide self-injury in youth.European Psychiatry, 29503-508. doi:10.1016/j.europsy.2014.02.008
Sansone, R. A., & Sansone, L. A. (2010). Measuring Self-Harm Behavior with the Self-Harm Inventory. Psychiatry (Edgmont), 7(4), 16–20.
Turner, B. J., Dixon-Gordon, K. L., Austin, S. B., Rodriguez, M. A., Zachary Rosenthal, M., & Chapman, A. L. (2015). Non-suicidal self-injury with and without borderline personality disorder: Differences in self-injury and diagnostic comorbidity. Psychiatry Research, 23028-35. doi:10.1016/j.psychres.2015.07.058
Whitlock, J.L., Exner-Cortens, D. & Purington, A. (under review). Validity and reliability of the non-suicidal self-injury assessment test (NSSI-AT).