Non-suicidal Self Injury

Introduction

As the name of this disorder suggests, nonsuicidal self injury (NSSI) is characterized by injuring one’s own body tissues without the intention of committing suicide. However, some studies have reported repeated self-injury to subsequently be associated with suicide attempts; this leads us to believe that the underlying psychology behind these tendencies may lie on the same risk trajectory. Initially there was a lack of awareness and attention to this condition due to inadequate scientific literature, but the last two decades have been game changing with constructive research that yielded new knowledge of its forms, functions, prevalence, association with psychiatric morbidity and the need to identify it as a syndrome by itself. There has been a proposal to include NSSE as a separate psychiatric diagnosis in the DSM-5 (Diagnostic and Statistical Manual of Mental disorders, fifth edition). While some have expressed their support, there is dissent among others due to the separation of suicidal and nonsuicidal self injury despite a considerable overlap between the two behaviors.The fact that NSSI is associated with emotional and psychiatric distress and an increased risk of suicidal tendency, has made it crucial to conceptualize accurately the clinical models of this type of behavior in order to facilitate future efforts to understand and treat this condition better.

Who Is Affected by Non-Suicidal Self Injury?

It is most commonly prevalent in adolescents and young adults starting typically at the age of 13 or 14.. Studies have shown that 7 to 14% of adolescents injure themselves deliberately at least once and there was found to be a higher one year prevalence rate of about 24% which suggests that the prevalence may be rising. About 6% of adults have reported a history of NSSE. There was thought to be a significantly higher prevalence of NSSE among females than males, however, general population studies showed equal rates in men and women. Though adolescents living in different regions of the world are exposed to unique socio cultural circumstances, prevalence rates in different countries seem to be more or less the same. NSSI was noted to be more common in people with a nonheterosexual orientation (homosexual, bisexual, questionable sexuality, etc.); it is also reported more in Caucasians than non-Caucasians. NSSE is associated with other personality disorders like borderline personality disorder, anxiety, depression, post-traumatic stress disorder and eating disorders, autism, antisocial personality disorder, etc.

Risk factors for NSSE include:

• Individuals with emotional dysregulation and low distress tolerance.

• A history of drug or alcohol abuse.

• History of trauma, physical, sexual or emotional abuse. Growing up in an unstable environment with family issues also increases the risk of developing self-harming tendencies.

• Extremes of emotions; either emotionless or very emotional.

• Loneliness or feeling of isolation.

• Prolonged suppression of emotions .

• Anxiety and depression.

• Influence of friends with the habit of self-harm.

What Could Be the Possible Causes of Non-Suicidal Self Injury?

NSSI does not result from a single cause. The functions of NSSI can be categorized as intrapersonal (persons self-injure for reasons concerning themselves) and interpersonal (self-injury aimed at affecting others). Some of the reasons due to which individuals may indulge in self-injury are:

• It could be a mechanism of attaining relief from intense distressing affect - emotional, physical, spiritual or social suffering that makes an individual feel fear, loneliness, anxiety, depression or sadness.

• NSSI can be due to the need for self-punishment as a result of extreme criticism of oneself, they feel they deserve the pain as punishment.

• To draw attention towards one’s distress or communicate one’s pain to the world.

• To induce guilt and changes in the behavior of others.

• To distract oneself with physical pain for escaping emotional pain.

• As the way to feel in control of one’s body, feelings and situations.

Two underlying mechanisms at play in NSSI are:

1. Poor/Inadequate Coping Skills - Due to the Inability to cope with stress and pain in healthy ways.

2. Poor Management of Emotions - A difficulty in expression or suppression of emotions. A complex mix of emotions like worthlessness, anger, self-hatred, guilt, etc. may trigger NSSI.

What Are the Types of Self Injury?

Self-injury is often inflicted in private and the method of causing injury is likely to be uniform. This results in scar patterns or similar injury marks on the skin. Examples of self-harm include:

• Injuring oneself with cuts, scratches, or the use of a sharp object for stabbing, are common modes of self-injury

• Burns with lighters, matches, cigarette butts or heated, sharp objects such as knives.

• Carving one’s skin with symbols or words

• Punching into walls, hitting/banging the head against hard objects,

• Using sharp objects like pins to pierce one’s skin.

• Insertion of objects under one’s skin.

What Are the Features of Non-suicidal Self Injury?

Self-injuring activities provide short-term relief from distressing thoughts and feelings, however in the long-term it has negative consequences. Signs of NSSE include:

• Visible scars on the arms, legs or stomach. Any part of the body may be chosen for deliberate injury. Fresh wounds may be noticed frequently.

• One often wears fully covered clothing like full sleeves and pants even when the weather is not cold to cover the marks

• Abstaining oneself from activities they enjoy.

• Signs of depression and anxiety may be present.

• If questioned about scars or wounds, they attribute it to accidents.

• Difficulties in interpersonal relationships.

• Frequently changing behavior and emotions, acting on impulse.

• Expression of helplessness, or worthlessness in conversations.

• Sharp objects or other modes of self-injury are kept handy.

How to Cope With NSSE?

Management of NSSE should aim at identifying the processes or cause for self-harm and must improve the regulation and tolerance of emotions. Assessment involves determining the type, frequency, duration, etc of the injury and screening for coexisting psychiatric disorders. Estimating the risk of suicide and willingness of the individual for treatment is important.

Cognitive behavioral therapies like Dialectical behaviour therapy (DBT) and Emotion-regulation group therapy (ERGT) have been shown to be effective in reducing non-suicidal self-injury.

• DBT entails a year of individual and group therapy. This therapy helps in detecting and changing problematic thought patterns, as well as supports positive improvements. It seeks to assist patients in developing appropriate stress responses (eg, resisting urges to behave self-destructively).

• On the other hand, ERGT is performed in a group setting for 14 weeks. This therapy teaches patients to become more conscious of their emotions and equips them with techniques for dealing with them. ERGT teaches patients acceptance of negative emotions as they are a part of life so as to not respond to such feelings impulsively.

• Coexisting personality or psychiatric disorders must be treated as required.

Currently there is no approved pharmacological treatment for NSSE. Some antipsychotics were shown to be useful.

Physical complications like infection and scarring, and emotional complications like worsening of guilt, shame and self-esteem can occur if NSSE is not intervened and treated.

Conclusion

Non-suicidal self-injury is a common tendency in adolescents occuring either in isolation or in conjunction with other psychiatric and behavioral disorders. It involves intensely negative thoughts, feelings and leads to negative social, physical and emotional consequences. It may be explained as an unhealthy coping mechanism or to occur due to the difficulty an individual faces in managing emotions and is associated with an increased risk of suicide. The recognition of NSSE as a separate psychiatric entity will improve research, communication and the development of specific and targeted treatment approaches addressing the underlying cause. It is important to identify and help people showing nonsuicidal self-harm, otherwise the viscous cycle of self harm may worsen when the relief these individuals experience from indulging in self-harm wanes.