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Nonsuicidal self-injury: How categorization guides treatment

Article in Current Psychiatry · March 2012

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Nonsuicidal self-injury: How
categorization guides treatment
Understanding how and
why patients engage in NSSI
leads to optimal care

F
ormerly called self-mutilation, self-injury, or self-
harm, nonsuicidal self-injury (NSSI) is the deliber-
ate and direct alteration or destruction of healthy
body tissue without suicidal intent; these behaviors
range from skin cutting or burning to eye enucleation
or amputation of body parts. NSSI must be deliberate,
as opposed to accidental or indirect behaviors—such
as overdoses or ingesting harmful substances—that
cause injury that is uncertain, ambiguous as to course,
or invisible (the injuries do not disfigure observable
body tissue).1 NSSI acts are done without an intent to
© IKON IMAGES/CORBIS

die, although persons who self-harm may have sui-

cidal ideation and passive thoughts of dying.2 Persons
who repeatedly engage in NSSI and are demoralized
over their inability to control it are at risk for suicide
attempts.3
NSSI can be classified as nonpathological or patho- Armando R. Favazza, MD
Emeritus Professor of Psychiatry
logical.4 Culturally sanctioned, nonpathological NSSI
University of Missouri-Columbia
consists of body modification practices such as tattoos Columbia, MO
or piercing. Body modification practices may be a sub-
limation of pathological NSSI. For a description of non-
pathological NSSI, see the Box (page 22).5 Pathological
NSSI typically is a method of emotional regulation.
Understanding why patients engage in pathological
NSSI and how it is categorized can help guide assess-
ment and treatment.

Why people engage in NSSI

NSSI is best regarded as a pathological approach to emo-
Current Psychiatry
tional regulation and distress tolerance that provides Vol. 11, No. 3 21
 Box

Body modification: When self-injury is not pathological

B ody modification practices and rituals are

culturally sanctioned forms of nonsuicidal
self-injury (NSSI). Body modification practices
destabilizing conditions that threaten people
and communities, such as mental and
physical diseases; angry gods, spirits, or
include tattooing and piercing earlobes, nipples, ancestors; failure of children to accept adult
and other body parts to accommodate jewelry. responsibilities; conflicts (eg, male-female,
Nonsuicidal Most practices are harmless but when carried intergenerational, interclass, intertribal);
self-injury to extremes, they may point to underlying loosening of clear social role distinctions; loss
neuroses. For some patients, a tattoo or piercing of group identity; immoral or sinful behaviors;
may be psychologically beneficial—eg, to and ecological disasters.
reclaim one’s body after an attack or rape.5 These rituals are effective because
Body modification rituals, such as head participants believe they promote healing,
gashing by Sufi healers, penis cutting during spirituality, and social order. Knowledge about
aboriginal coming-of-age ceremonies, body modification practices and rituals in which
and Hindu body piercing to attain spiritual NSSI is perceived to be therapeutic opens
goals, are meaningful activities that reflect the door to an understanding of pathological
the tradition, symbolism, and beliefs of a NSSI as a form of self-help behavior and allows
Clinical Point society. These rituals serve an elemental clinicians to have a more empathic interaction
purpose by correcting or preventing with patients who self-injure.
NSSI may fall
within 4 descriptive
categories: major, rapid but temporary relief from disturb- The functional model is key to provid-
stereotypic, ing thoughts, feelings, and emotions. For ing thorough clinical evaluations that
compulsive, or approximately 90% of patients, NSSI de- should include understanding the ante-
creases symptoms, most commonly unten- cedent and consequent thoughts, feelings,
impulsive
able anxiety (“It’s like popping a balloon”), situations, triggers, and vulnerabilities re-
depressed mood, racing thoughts, swirling lated to NSSI acts.
emotions, anger, hallucinations, and flash-
backs.6,7 In some instances, NSSI generates
desired feelings and self-stimulation dur- The medical approach
ing periods of dissociation, depersonaliza- A descriptive, phenomenological model of
tion, grief, insecurity, loneliness, extreme NSSI classification uses concepts and ter-
boredom, self-pity, and alienation.8,9 NSSI minology with which most psychiatrists
also may signal distress to elicit a caring re- are familiar, takes into account patients
sponse from others or provide a means of who have comorbid psychiatric disor-
escape from intolerable social situations.10 ders, is based on atheoretical, descriptive
Table 1 lists factors associated with NSSI. observations, and fits into what might be
regarded as a “medical model.” In this
classification, NSSI usually is regarded as a
The functional approach symptom or associated feature of a specific
One model of classifying NSSI focuses on psychiatric disorder, although it may oc-
the behavioral functions it serves.11,12 In cur in persons who do not meet diagnostic
this model, the most common function of criteria of a mental illness—eg, “copycat”
NSSI is removal or escape from an aver- cutting in high school students.13,14 NSSI
ONLINE
ONLY sive affective or cognitive state (automatic may fall within 4 descriptive categories:
positive reinforcement). Automatic nega- major, stereotypic, compulsive, or impul-
Discuss this article at tive reinforcement explains using NSSI sive. For psychiatric disorders associated
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to generate feelings—eg, by patients with with these types of pathological NSSI, see
CurrentPsychiatry
anhedonia or numbness. NSSI also may Table 2 (page 24).
be used as a signal of distress to gain at-
tention, access helpful environmental re- Major NSSI includes infrequent acts that
sources (social positive reinforcement), or destroy significant body tissue, such as eye
remove distressing interpersonal demands enucleation and amputation of body parts.
Current Psychiatry
22 March 2012 (social negative reinforcement). They are sudden, messy, and often bloody
acts. Seventy-five percent occur during a Table 1
psychotic state, mainly schizophrenia; of
these, approximately one-half occur dur- Factors associated with NSSI
ing a first psychotic episode.15 The reasons High levels of negative and unpleasant
patients typically offer for such behavior thoughts and feelingsa
often defy logical understanding—eg, to Poor communication skills and problem-
enhance general well-being—but most solving abilitiesb
center on religion, such as a concrete inter- Abuse, maltreatment, hostility, and marked
criticism during childhoodc,d
pretation of biblical texts about removing
an offending eye or hand or becoming an Under- or over-arousal responses to stressb

eunuch,16,17 or on sexuality, such as con- High valuation of NSSI to achieve a desired

responsee
trolling troubling hypersexuality or fear
Need for self-punishmenta
of giving in to homosexual urges.18
Modeling behaviors based on exposure
to NSSI among peers, on the Internet—ie,
Stereotypic NSSI acts, most commonly as- postings on YouTube—and in the mediaf
sociated with severe and profound mental NSSI: nonsuicidal self-injury
retardation, include repetitive head bang- Source: For reference citations, visit this article at Clinical Point
CurrentPsychiatry.com
ing; eye gouging; biting lips, the tongue, One or 2 impulsive
cheeks, or fingers; and face or head slap-
NSSI acts do not
ping. The behaviors may be monotonously
repetitive, have a rhythmic pattern, and be preoccupied with their NSSI, may carve have prognostic
performed without shame or guilt in the words into their skin, and may perform importance unless
presence of onlookers. acts of self-harm with other self-injurers. they are serious
Some may cut themselves hundreds or
enough to warrant
Compulsive NSSI encompasses repetitive even thousands of times, creating scars
behaviors such as severe skin scratching that result in social morbidity. They an ED visit
and nail biting, hair pulling (trichotil- often seek professional help avidly, but
lomania), and skin digging (delusional may become so demoralized over their
parasitosis). inability to stop their NSSI that they are
at risk for suicide.3 In some repetitive self‑­
Impulsive NSSI consists of acts such as injurers, other impulsive behaviors such
skin cutting, burning, and carving; stick- as bulimia or substance abuse may alter-
ing pins or other objects under the skin nate or coexist with NSSI. This pattern of-
or into the chest or abdomen; interfering ten runs its course in 5 to 15 years and may
with wound healing; and smashing hand end abruptly, especially in patients with
or foot bones. These behaviors usually are borderline personality disorder.
episodic and occur more frequently in fe-
males. The average age of onset in patients
who engage in impulsive NSSI is 12 to 14, First-line treatment: Psychotherapy
although it may occur throughout the life Many studies have demonstrated the ef-
cycle. ficacy of psychotherapy as the primary
One or 2 isolated instances of impulsive treatment for NSSI.19-21 Except for patients
NSSI do not have much prognostic impor- with Lesch-Nyhan syndrome or other rare
tance unless they are serious enough to neurologic syndromes, the biologic causes
warrant an emergency department visit. of NSSI, including the role of endogenous
The real danger is when the behavior be- opioids, are unclear. No medications are
comes repetitive and “addictive.” The FDA-approved for NSSI. Pharmacotherapy
crossover from episodic to repetitive usu- may help NSSI patients, but such treatment
ally varies from 5 to 10 episodes. recommendations are based on clinical ex-
Persons who engage in repetitive perience, and polypharmacy is common.22
NSSI may use multiple methods, but skin Studies have not demonstrated specific
cutting predominates. Such persons often benefits or consistent efficacy of pharma-
Current Psychiatry
develop a self-identity as a “cutter,” are cotherapy for NSSI.23 Vol. 11, No. 3 23
continued
 Table 2

Psychiatric disorders associated with pathological NSSI

Type of NSSI Related psychiatric disorders
Major Alcohol/drug intoxication, body integrity identity disordera
Stereotypic Autism,b Tourette’s syndrome,c Lesch-Nyhan syndrome,d hereditary
neuropathies,e mental retardation
Nonsuicidal Compulsive Trichotillomania, delusional parasitosis
self-injury Impulsive Anxiety disorders (generalized, acute stress, posttraumatic stress, obsessive-
compulsive, substance-inducedf-h); borderline, histrionic, and antisocial
personality disordersi,j; somatoform and factitious disordersk,l; dissociative
identity and depersonalization disordersm,n; anorexia and bulimia nervosao,p;
depressive disordersq,r; bipolar disorders; schizophreniat,u; alcohol use disorderv;
kleptomaniaw
NSSI: nonsuicidal self-injury
Source: For reference citations, visit this article at CurrentPsychiatry.com

Clinical Point
No medications are Major NSSI. Prevention is key to addressing may be effective. N-acetylcysteine, 600 mg
major NSSI. Consider atypical antipsychot- twice a day, may relieve trichotillomania.25
FDA-approved for
ics for psychotic patients who are preoccu- Treatment should include psychotherapy.
NSSI but clinical pied with religion, the Bible, or sexuality,
experience suggests as well as those who dramatically and sud- Impulsive NSSI. Patients who engage in
pharmacotherapy denly change their appearance by cutting episodic impulsive NSSI should receive
off their hair, engaging in extreme body pharmacotherapy for underlying psychi-
may help some NSSI
modification practices, or wearing bizarre atric illnesses such as generalized anxiety
patients clothes.24 In my clinical experience, agitated disorder, posttraumatic stress disorder, or
patients who have committed major NSSI depression. Do not automatically diagnose
are at high risk for a second episode and borderline personality disorder. Patients
should receive pharmacotherapy based on whose NSSI behavior is uncontrollable
treatment guidelines and hospitalized until initially should receive high doses of
the agitation is controlled. SSRIs that can be lowered when impul-
sivity decreases, atypical antipsychotics,
Stereotypic NSSI. Patients with this form and a mood stabilizer such as lamotrigine.
of NSSI often cannot articulate what is Psychotherapy is vital, especially dialecti-
bothering them. With input from caretak- cal behavior therapy. Cognitive-behavioral
ers, assess the likelihood that a patient is and interpersonal therapies also are effec-
reacting to pain. Analgesics may be ef- tive, as is psychodynamic therapy.19-21
fective. Also check for infections such as NSSI patients and their families may
otitis media. Selecting a medication can be benefit from Web sites that provide infor-
challenging. Start with a moderate dose mation, advice, monitored blogs, and sup-
of a selective serotonin reuptake inhibitor port groups (see Related Resources).
(SSRI), then slowly add an atypical anti-
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Bottom Line
Pathological nonsuicidal self-injury (NSSI) can be categorized as major, stereotypic,
compulsive, and impulsive. Studies have shown psychotherapy, especially dialectical
and other behavioral therapies, are effective primary treatments for several types of
NSSI. Pharmacotherapy should be used in NSSI patients with underlying psychiatric
illnesses, such as, generalized anxiety disorder, posttraumatic stress disorder, or
Current Psychiatry
depression. Vol. 11, No. 3 25
 Table 1

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