Impulsive-addictive-compulsive Types of Non-suicidal Self-injury: A Case Series

Non-suicidal self-injury (NSSI) refers to purposeful self-inflicted harm without any suicidal intentions, encompassing behaviors like skin picking, cutting, and scratching the exteriors of the body.^1,2 Such self-harming tendencies are observed across a spectrum of psychiatric conditions, including depressive disorders, other mood disorders, posttraumatic stress disorder (PTSD), and dissociative disorder.^3-5 A meta-analysis conducted in 2014 highlighted that the prevalence of NSSI among adolescents is approximately around 17%. ⁶

Adolescence is a period with important biological and neurodevelopmental changes bringing in substantial emotional and behavioral variations. While most adolescents navigate this period with relative ease, some adolescents find it difficult to manage their experiences due to temperamental and environmental reasons. In some strong negative emotions, they experiment with maladaptive coping behaviors, such as substance use, disordered eating patterns, and NSSI. ⁷

The motivations behind engaging in self-harm are diverse; qualitative investigations have identified themes such as seeking relief from overwhelming emotions, self-punishment, and as a means to communicate distress. ⁸ Conversely, NSSI can function as an emotional regulation mechanism. By engaging in self-injury, individuals might experience temporary relief from overwhelming emotions, thereby reducing the immediate risk of suicidal behavior. This is because NSSI can help to distract from emotional pain or can lead to a release of endorphins, providing a short-term sense of relief or control.^4,9-11

Generally, the reason for NSSI is usually associated with impulse control problems. It is hypothesized through a mechanism of negative urgency, where significant stressors, emotional distress, trauma, and feelings of numbness can make a person inflict self-injury. Negative urgency refers to a tendency to act impulsively, such as self-injurious behaviors, substance abuse, and binge eating, following emotional distress. ¹² Further, studies in this regard have shown that people who engage in NSSI report higher impulsivity than those who do not engage in it.^13,14 However, in some cases, NSSI can also be influenced by additional factors such as obsessive thoughts and compulsive urges related to self-harm. Given this, the former type of NSSI can be considered ego-syntonic in nature, whereas the latter type is ego-dystonic. Further, the ego-syntonic type can be considered as a result of impulsivity related to significant distress, and the ego-dystonic type as a result of an attempt to avoid distress. Like many comorbid mental disorders, NSSI can be the result of impulsivity induced by distress (negative urgency), as well as obsessive-compulsive phenomena. There is little literature on understanding self-harm behaviors when multiple elements are involved in the same case. ¹⁵

The following case series illustrates the impulsive, compulsive, and addictive aspects of NSSI in adolescents. Informed assent and consent were obtained from the adolescents and their parents, respectively, to report the cases. For all the cases presented below, the International Classification of Diseases 10 (ICD 10), ¹⁶ criteria were used.

Case Series

Case 1

Ms T is a 16-year-old girl studying in 12^th standard from middle socioeconomic status (SES). The adolescent was brought to child and adolescent psychiatry (CAP) services with complaints of low mood, lack of sleep and appetite, suicidal thoughts/urges, and a history of NSSI. She was diagnosed with moderate depressive episodes according to the ICD-10 criteria. ¹⁶ Ms T had a slow-to-warm-up temperament. Her mother was diagnosed with depression when T was 10 years old, and she died (alleged suicide) when T was 12 years old. Prior to that, there was significant marital discord between parents. Three years after her mother’s death, her father remarried, and the adolescent had a cordial relationship with her stepmother. Upon clinical interview, Ms T reported that she has been inflicting self-harm since she was eight years of age by cutting and scratching.

Ms T’s primary reason for engaging in self-harm was to release the built-up emotional pressure, especially during the conflict between her parents, which significantly increased after the death of her mother. She reported that “I used to pick my wounds or scratch my thighs with my fingernails; I hate it when they fight; I do not know what to do other than this. Now this (act of self-harm) became permanent in me.” Given this, initially, it was considered that her NSSI was due to impulsivity and emotional distress. However, upon in-depth inquiry, she reported that 50% of the time, her self-harm behavior was due to interpersonal and psychological contributors (death of her mother, her father’s remarriage, the feeling of emptiness, loneliness), and another 50% of the time, something else that she could not verbally comprehend. On further questioning, the adolescent reported that she had tension and an urge to carry out the self-harm. She reported that the primary purpose of self-harm is to escape from the internal pain. However, she further reported that she would get the urge to harm herself for no apparent reason, which she finds unable to resist: “It is like I am craving to cut myself. I do not want that, but those of harming self, repetitively occur in my head, no matter how much I resist…. I will get relief only If I cut and see the blood.” She distinguished two types of self-harm behavior: Harming herself to escape pain when there is distress, which could be postponed, and harming herself due to an urge, which she could not postpone. The latter, compulsive self-harm behavior, was less controllable, occurring independently of her emotional state and interpersonal or external circumstances “I get this urge even when I am happy or talking to you or friends. It is always in the background in my head.”

Ms T’s self-harm served dual purposes, involving both distress-induced and urge-driven elements, highlighting the complexity of her condition. However, the second type, which is compulsive, was only identified after repeated interviewing during therapy when authors tried to understand the phenomenology of the NSSI.

Case 2

Master S, a 16-year-old boy studying in the 12^th grade from an upper SES, was brought to CAP services with symptoms of persistent low mood, aggressive behavior, NSSI, suicidal and obsessive thoughts related to death, contamination, and compulsions. He was reported to be a temperamentally slow-to-warm-up child. The adolescent reported that his obsessive thoughts related to contamination had started when he was 14 years old. He reported that since then, he has had low mood and obsessive thoughts related to death. These symptoms were exacerbated after being bullied by other classmates for his physical appearance. No history of any psychiatric illness in the family or other environmental adversities has been reported. He was diagnosed with moderate depressive episodes and obsessive-compulsive disorder (OCD) according to the ICD-10 criteria. ¹⁶ Upon further detailed interview, Master S shared that in addition to his obsessive thoughts about contamination, he frequently experiences intense suicidal thoughts; however, he could not express any intention behind these suicidal thoughts. These thoughts are not typical of regular suicidal ideation but rather manifest as an overwhelming, obsessive thought that persists in his mind. Despite his efforts to avoid these thoughts, they intrude on his consciousness involuntarily. He reported being terrified by these thoughts, fearing that they might drive him to commit suicide.

Engaging in self-harm is my way of delaying suicide. It provides temporary relief from these suicidal thoughts. My family believes I am intentionally causing harm to myself or that I am in control, but the reality is that I am not. While I have some limited control, I often experience a strong urge to engage in self-harming behaviors

Master S elaborated that he experiences an intense, almost physical urge to cut/hurt himself. He described this sensation as an obsessive urge that he can feel both mentally and physically, akin to an addiction. He expressed, “I can feel it in my body, both mentally and physically. I think I crave it, and I can only stop it if I hurt myself. Only if I cut/hurt myself do I get relief. I cannot control it.” This case highlights the complexity of Master S’s condition, where his self-harm behaviors are intertwined with his obsessive-compulsive symptoms and severe depressive thoughts. This behavior involves distress-induced impulsive urges, cravings, as well as a compulsive element to self-harm.

Case 3

Miss A, a temperamentally difficult 17-year-old girl from an upper-middle SES, was brought to the CAP following a suicide attempt in which she had cut her wrist. She presented with symptoms of persistent low mood, sleep disturbances, impulsive behaviors, repeated attempts of NSSI, suicidal thoughts, and nicotine addiction since 15 years of age. She reported a history of childhood sexual abuse at 16 years, after which her mood symptoms deteriorated, and her suicidal thoughts have increased. She reported that suicidal thoughts are related to shame and guilt of sexual abuse. She also reported engaging in repetitive behaviors such as counting, locking, and checking her belongings since she was 13 years old. There was no history of psychiatric illness in the family or any other environmental adversities. Miss A was diagnosed with mild depressive episodes, OCD, and nicotine dependence syndrome according to the ICD-10 criteria. ¹⁶ Miss A described that she resorted to self-harm as she had a craving to experience pleasure and temporarily alleviate the emotional emptiness. Engaging in self-harm provided her with a tangible way to feel something and served as a reminder that she was still alive inside. Upon in-depth evaluation, she explained that while she initially turned to self-harm to fill the emotional void, it eventually evolved into a kind of addiction. She reported,

There were times when I would crave the act of self-harm (cutting). I would think, ‘Okay, I did not self-harm during the day today. I will do it at night,’ or I would even plan for it. It has become a part of who I am, and I have become accustomed to it.

Miss A further explained that she could delay the act of self-harm, but the urge to hurt herself was always present in the back of her mind. Even though she could delay it, she wanted to cut herself to get relief from the distress arising from the urge. She differentiated two different types of self-harm: one driven by external triggers and another by an internal, inexplicable urge. She stated, “If something annoys me, yeah, I would cut myself. There is something else also—the urge that is different; it comes for no reason. I do not want it. Nobody wants it, right?” Miss A’s self-harm served multiple purposes: it provided temporary relief from emotional emptiness and distress, and it had become an addictive behavior that she craved. Her case illustrates the multiple nature of her self-harm behaviors, involving situationally triggered impulses, an internally driven compulsion, and addictive behavior.

Discussion

The presented cases illuminate the intricate and multifaceted nature of NSSI, encompassing a spectrum of self-harming behaviors devoid of suicidal intent. NSSI was often linked with impulsivity. A meta-analysis pointed out that NSSI is often associated with increased self-reported impulsivity. ¹⁷ The theory of “Negative urgency, Experiential avoidance, and Four functional models of NSSI” provides a detailed framework for the role of impulsivity in NSSI. ¹⁰ Apart from distressed/impulsivity-induced NSSI, literature has given an addictive framework for NSSI as well. Notably, recent studies, ¹⁸ have emphasized that repetitive NSSI can be comprehended within the framework of addictive behavior. This perspective is substantiated by research associating the emotional states preceding NSSI with aversive withdrawal symptoms akin to those experienced by individuals with substance use disorders.^19,20 In this regard, investigations found that 81% of adolescents with repetitive NSSI fulfilled few Diagnostic and Statistical Manual (DSM)-IV criteria indicative of symptoms of dependence, such as tolerance, persistence despite recognizing harm, social problems, and the recurrence of tension if the behavior was discontinued. ²⁰

While a substantial body of literature explores the connection between NSSI and impulsivity, according to the available knowledge, only one qualitative study with a small sample size has focused on and found that compulsive urges are also associated with NSSI. It is also crucial to look at NSSI in a broad impulsive-compulsive spectrum. This will help us to differentiate how impulsive as well as compulsive factors drive self-harm. Though NSSI often starts as an impulsive act, it could develop as a compulsive pattern over time. Impulsive NSSI is often linked to emotional regulation, whereas compulsive NSSI is used to reduce the distress from the repetitive urge to self-harm. Both aspects could co-exist in an individual at the same time. Adolescents often fail to articulate this compulsive nature of NSSI or may not even realize that their behavior is compulsive due to many factors, such as a lack of emotional and metacognitive awareness and limited vocabulary. Further, Psychosocial factors such as shame, guilt, and social stigma could also avert them from disclosing the compulsive nature of NSSI. It is always easy to explain NSSI as a reaction to some active stressor rather than explaining the complexity of thoughts in their mind. Clinicians and other mental health professionals often fail to look at the compulsive aspect of NSSI. This necessitates further research to comprehensively understand NSSI with a focus on compulsive aspects of self-harm, providing valuable insights for both clinical practice and theoretical frameworks.

It is crucial to recognize that NSSI is not a homogeneous phenomenon; instead, it manifests with diverse motivations and can be influenced by various psychiatric conditions. The case series of Ms T, Mr S, and Ms A, detailed above, provide unique insights into their compulsive urges that contribute to NSSI. Ms T’s case shows both external distress and compulsive urges as reasons for self-harm. Mr S’s case emphasizes the link between NSSI and obsessive thoughts, illustrating how engaging in self-harm serves as a coping mechanism to delay obsessive suicidal thoughts. Ms A’s case delves into how NSSI results from a response to emotional emptiness to a response to the craving, emphasizing another dimension of NSSI, which is “addictive self-harm.”

Conclusion

To our knowledge, only one study has explored the compulsive aspect of NSSI. ⁸ The cases mentioned above are examples of multiple motivational factors affecting NSSI, including addictive and compulsive aspects, which are sometimes difficult to notice and understand. This understanding contributes to a more comprehensive theoretical framework and holds implications for developing targeted interventions. In these conditions, interventions for NSSI should focus on and address each aspect of emotional distress, craving, and compulsive elements, in addition to addressing other symptoms. As this is a case series, some of the rigors of the scientific research could not be met; further research in this area is crucial for refining our understanding of NSSI and advancing effective therapeutic approaches for individuals grappling with this complex behavior.

Supplemental Material

Supplemental material for this article is available online.